pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_d_opt_use_mand_16b_yn	pbp_d_opt_use_mand_16b1_yn	pbp_d_opt_use_mand_16b2_yn	pbp_d_opt_use_mand_16b3_yn	pbp_d_opt_use_mand_16b4_yn	pbp_d_opt_use_mand_16b5_yn	pbp_d_opt_use_mand_16b6_yn	pbp_d_opt_use_mand_16c_yn	pbp_d_opt_use_mand_16c1_yn	pbp_d_opt_use_mand_16c2_yn	pbp_d_opt_use_mand_16c3_yn	pbp_d_opt_use_mand_16c4_yn	pbp_d_opt_use_mand_16c5_yn	pbp_d_opt_use_mand_16c6_yn	pbp_d_opt_use_mand_16c7_yn	pbp_d_opt_use_mand_16c8_yn	pbp_d_opt_use_mand_16c9_yn	pbp_d_opt_use_mand_16c10_yn	pbp_b16b_maxplan_pv_yn	pbp_b16b_maxplan_pv_in_oon	pbp_b16b_maxplan_pv_amt	pbp_b16b_maxplan_pv_per	pbp_b16b_maxplan_pv_per_desc	pbp_b16b_maxenr_pv_yn	pbp_b16b_maxenr_pv_amt	pbp_b16b_maxenr_pv_per	pbp_b16b_maxenr_pv_per_desc	pbp_b16b_coins_ov_yn	pbp_b16b_coins_ov_svcs	pbp_b16b_coins_ov_pct	pbp_b16b_coins_ov_pct_min	pbp_b16b_coins_ov_pct_max	pbp_b16b_copay_ov_yn	pbp_b16b_copay_ov_svcs	pbp_b16b_copay_ov_amt	pbp_b16b_copay_ov_amt_min	pbp_b16b_copay_ov_amt_max	pbp_b16b_ded_pv_yn	pbp_b16b_ded_pv_amt	pbp_b16b_bendesc_oe_amo	pbp_b16b_bendesc_oe_lim	pbp_b16b_bendesc_oe_num	pbp_b16b_bendesc_oe_per	pbp_b16b_bendesc_oe_desc	pbp_b16b_coins_oe_yn	pbp_b16b_coins_oe_pct	pbp_b16b_coins_oe_pct_min	pbp_b16b_coins_oe_pct_max	pbp_b16b_copay_oe_yn	pbp_b16b_copay_oe_amt	pbp_b16b_copay_oe_amt_min	pbp_b16b_copay_oe_amt_max	pbp_b16b_auth_oe_yn	pbp_b16b_refer_oe_yn	pbp_b16b_bendesc_dx_amo	pbp_b16b_bendesc_dx_lim	pbp_b16b_bendesc_dx_num	pbp_b16b_bendesc_dx_per	pbp_b16b_bendesc_dx_desc	pbp_b16b_coins_dx_yn	pbp_b16b_coins_dx_pct	pbp_b16b_coins_dx_pct_min	pbp_b16b_coins_dx_pct_max	pbp_b16b_copay_dx_yn	pbp_b16b_copay_dx_amt	pbp_b16b_copay_dx_amt_min	pbp_b16b_copay_dx_amt_max	pbp_b16b_auth_dx_yn	pbp_b16b_refer_dx_yn	pbp_b16b_bendesc_ods_amo	pbp_b16b_bendesc_ods_lim	pbp_b16b_bendesc_ods_num	pbp_b16b_bendesc_ods_per	pbp_b16b_bendesc_ods_desc	pbp_b16b_coins_ods_yn	pbp_b16b_coins_ods_pct	pbp_b16b_coins_ods_pct_min	pbp_b16b_coins_ods_pct_max	pbp_b16b_copay_ods_yn	pbp_b16b_copay_ods_amt	pbp_b16b_copay_ods_amt_min	pbp_b16b_copay_ods_amt_max	pbp_b16b_auth_ods_yn	pbp_b16b_refer_ods_yn	pbp_b16b_bendesc_pc_amo	pbp_b16b_bendesc_pc_lim	pbp_b16b_bendesc_pc_num	pbp_b16b_bendesc_pc_per	pbp_b16b_bendesc_pc_desc	pbp_b16b_coins_pc_yn	pbp_b16b_coins_pc_pct	pbp_b16b_coins_pc_pct_min	pbp_b16b_coins_pc_pct_max	pbp_b16b_copay_pc_yn	pbp_b16b_copay_pc_amt	pbp_b16b_copay_pc_amt_min	pbp_b16b_copay_pc_amt_max	pbp_b16b_auth_pc_yn	pbp_b16b_refer_pc_yn	pbp_b16b_bendesc_ft_amo	pbp_b16b_bendesc_ft_lim	pbp_b16b_bendesc_ft_num	pbp_b16b_bendesc_ft_per	pbp_b16b_bendesc_ft_desc	pbp_b16b_coins_ft_yn	pbp_b16b_coins_ft_pct	pbp_b16b_coins_ft_pct_min	pbp_b16b_coins_ft_pct_max	pbp_b16b_copay_ft_yn	pbp_b16b_copay_ft_amt	pbp_b16b_copay_ft_amt_min	pbp_b16b_copay_ft_amt_max	pbp_b16b_auth_ft_yn	pbp_b16b_refer_ft_yn	pbp_b16b_bendesc_ops_amo	pbp_b16b_bendesc_ops_lim	pbp_b16b_bendesc_ops_num	pbp_b16b_bendesc_ops_per	pbp_b16b_bendesc_ops_desc	pbp_b16b_coins_ops_yn	pbp_b16b_coins_ops_pct	pbp_b16b_coins_ops_pct_min	pbp_b16b_coins_ops_pct_max	pbp_b16b_copay_ops_yn	pbp_b16b_copay_ops_amt	pbp_b16b_copay_ops_amt_min	pbp_b16b_copay_ops_amt_max	pbp_b16b_auth_ops_yn	pbp_b16b_refer_ops_yn	pbp_b16c_maxplan_cmp_yn	pbp_b16c_maxplan_cmp_type	pbp_b16c_maxplan_cmp_in_oon	pbp_b16c_maxplan_cmp_amt	pbp_b16c_maxplan_cmp_per	pbp_b16c_maxplan_cmp_per_desc	pbp_b16c_maxenr_cmp_yn	pbp_b16c_maxenr_cmp_type	pbp_b16c_maxenr_cmp_amt	pbp_b16c_maxenr_cmp_per	pbp_b16c_maxenr_cmp_per_desc	pbp_b16c_ded_cmp_yn	pbp_b16c_ded_cmp_amt	pbp_b16c_bendesc_rs_amo	pbp_b16c_bendesc_rs_lim	pbp_b16c_bendesc_rs_num	pbp_b16c_bendesc_rs_per	pbp_b16c_bendesc_rs_desc	pbp_b16c_coins_rs_yn	pbp_b16c_coins_rs_pct	pbp_b16c_coins_rs_pct_min	pbp_b16c_coins_rs_pct_max	pbp_b16c_copay_rs_yn	pbp_b16c_copay_rs_amt	pbp_b16c_copay_rs_amt_min	pbp_b16c_copay_rs_amt_max	pbp_b16c_auth_rs_yn	pbp_b16c_refer_rs_yn	pbp_b16c_bendesc_end_amo	pbp_b16c_bendesc_end_lim	pbp_b16c_bendesc_end_num	pbp_b16c_bendesc_end_per	pbp_b16c_bendesc_end_desc	pbp_b16c_coins_end_yn	pbp_b16c_coins_end_pct	pbp_b16c_coins_end_pct_min	pbp_b16c_coins_end_pct_max	pbp_b16c_copay_end_yn	pbp_b16c_copay_end_amt	pbp_b16c_copay_end_amt_min	pbp_b16c_copay_end_amt_max	pbp_b16c_auth_end_yn	pbp_b16c_refer_end_yn	pbp_b16c_bendesc_peri_amo	pbp_b16c_bendesc_peri_lim	pbp_b16c_bendesc_peri_num	pbp_b16c_bendesc_peri_per	pbp_b16c_bendesc_peri_desc	pbp_b16c_coins_peri_yn	pbp_b16c_coins_peri_pct	pbp_b16c_coins_peri_pct_min	pbp_b16c_coins_peri_pct_max	pbp_b16c_copay_peri_yn	pbp_b16c_copay_peri_amt	pbp_b16c_copay_peri_amt_min	pbp_b16c_copay_peri_amt_max	pbp_b16c_auth_peri_yn	pbp_b16c_refer_peri_yn	pbp_b16c_bendesc_prm_amo	pbp_b16c_bendesc_prm_lim	pbp_b16c_bendesc_prm_num	pbp_b16c_bendesc_prm_per	pbp_b16c_bendesc_prm_desc	pbp_b16c_coins_prm_yn	pbp_b16c_coins_prm_pct	pbp_b16c_coins_prm_pct_min	pbp_b16c_coins_prm_pct_max	pbp_b16c_copay_prm_yn	pbp_b16c_copay_prm_amt	pbp_b16c_copay_prm_amt_min	pbp_b16c_copay_prm_amt_max	pbp_b16c_auth_prm_yn	pbp_b16c_refer_prm_yn	pbp_b16c_bendesc_mxpr_amo	pbp_b16c_bendesc_mxpr_lim	pbp_b16c_bendesc_mxpr_num	pbp_b16c_bendesc_mxpr_per	pbp_b16c_bendesc_mxpr_desc	pbp_b16c_coins_mxpr_yn	pbp_b16c_coins_mxpr_pct	pbp_b16c_coins_mxpr_pct_min	pbp_b16c_coins_mxpr_pct_max	pbp_b16c_copay_mxpr_yn	pbp_b16c_copay_mxpr_amt	pbp_b16c_copay_mxpr_amt_min	pbp_b16c_copay_mxpr_amt_max	pbp_b16c_auth_mxpr_yn	pbp_b16c_refer_mxpr_yn	pbp_b16c_bendesc_impl_amo	pbp_b16c_bendesc_impl_lim	pbp_b16c_bendesc_impl_num	pbp_b16c_bendesc_impl_per	pbp_b16c_bendesc_impl_desc	pbp_b16c_coins_impl_yn	pbp_b16c_coins_impl_pct	pbp_b16c_coins_impl_pct_min	pbp_b16c_coins_impl_pct_max	pbp_b16c_copay_impl_yn	pbp_b16c_copay_impl_amt	pbp_b16c_copay_impl_amt_min	pbp_b16c_copay_impl_amt_max	pbp_b16c_auth_impl_yn	pbp_b16c_refer_impl_yn	pbp_b16c_bendesc_prf_amo	pbp_b16c_bendesc_prf_lim	pbp_b16c_bendesc_prf_num	pbp_b16c_bendesc_prf_per	pbp_b16c_bendesc_prf_desc	pbp_b16c_coins_prf_yn	pbp_b16c_coins_prf_pct	pbp_b16c_coins_prf_pct_min	pbp_b16c_coins_prf_pct_max	pbp_b16c_copay_prf_yn	pbp_b16c_copay_prf_amt	pbp_b16c_copay_prf_amt_min	pbp_b16c_copay_prf_amt_max	pbp_b16c_auth_prf_yn	pbp_b16c_refer_prf_yn	pbp_b16c_bendesc_omsg_amo	pbp_b16c_bendesc_omsg_lim	pbp_b16c_bendesc_omsg_num	pbp_b16c_bendesc_omsg_per	pbp_b16c_bendesc_omsg_desc	pbp_b16c_coins_omsg_yn	pbp_b16c_coins_omsg_pct	pbp_b16c_coins_omsg_pct_min	pbp_b16c_coins_omsg_pct_max	pbp_b16c_copay_omsg_yn	pbp_b16c_copay_omsg_amt	pbp_b16c_copay_omsg_amt_min	pbp_b16c_copay_omsg_amt_max	pbp_b16c_auth_omsg_yn	pbp_b16c_refer_omsg_yn	pbp_b16c_bendesc_orth_amo	pbp_b16c_bendesc_orth_lim	pbp_b16c_bendesc_orth_num	pbp_b16c_bendesc_orth_per	pbp_b16c_bendesc_orth_desc	pbp_b16c_coins_orth_yn	pbp_b16c_coins_orth_pct	pbp_b16c_coins_orth_pct_min	pbp_b16c_coins_orth_pct_max	pbp_b16c_copay_orth_yn	pbp_b16c_copay_orth_amt	pbp_b16c_copay_orth_amt_min	pbp_b16c_copay_orth_amt_max	pbp_b16c_auth_orth_yn	pbp_b16c_refer_orth_yn	pbp_b16c_bendesc_ags_amo	pbp_b16c_bendesc_ags_lim	pbp_b16c_bendesc_ags_num	pbp_b16c_bendesc_ags_per	pbp_b16c_bendesc_ags_desc	pbp_b16c_coins_ags_yn	pbp_b16c_coins_ags_pct	pbp_b16c_coins_ags_pct_min	pbp_b16c_coins_ags_pct_max	pbp_b16c_copay_ags_yn	pbp_b16c_copay_ags_amt	pbp_b16c_copay_ags_amt_min	pbp_b16c_copay_ags_amt_max	pbp_b16c_auth_ags_yn	pbp_b16c_refer_ags_yn	pbp_d_opt_identifier
H0028	017	0	1	01	01	H0028_017_0	4	2	2	2		2			2	2		2							2	1		500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	021	0	1	01	01	H0028_021_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	053	3	1	01	01	H0028_053_3	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	082	0	1	01	01	H0028_082_0	6	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H0294	002	0	1	04	01	H0294_002_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	004	0	1	04	01	H0294_004_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	014	0	1	04	01	H0294_014_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	015	0	1	04	01	H0294_015_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	017	0	1	04	01	H0294_017_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	032	0	1	04	01	H0294_032_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0294	048	0	1	04	01	H0294_048_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0432	003	0	1	02	01	H0432_003_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0432	004	0	1	02	01	H0432_004_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0432	017	0	1	02	01	H0432_017_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0473	005	0	1	04	01	H0473_005_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0504	015	0	1	01	01	H0504_015_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	015	0	1	01	01	H0504_015_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	017	0	1	01	01	H0504_017_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	017	0	1	01	01	H0504_017_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	021	0	1	01	01	H0504_021_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	021	0	1	01	01	H0504_021_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Coinsurance range: Minimum coinsurance amount for excavation of a tooth resulting in the determination of non-restorability, maximum coinsurance amount for crown  resin-based composite (indirect).	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	026	0	1	01	01	H0504_026_0	8																			2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	026	0	1	01	01	H0504_026_0	8																			2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	028	0	1	01	01	H0504_028_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	028	0	1	01	01	H0504_028_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	038	0	1	01	01	H0504_038_0	8																			2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	038	0	1	01	01	H0504_038_0	8																			2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	039	0	1	01	01	H0504_039_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	001
H0504	040	0	1	01	01	H0504_040_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	040	0	1	01	01	H0504_040_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	041	0	1	01	01	H0504_041_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	041	0	1	01	01	H0504_041_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	043	0	1	01	01	H0504_043_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	043	0	1	01	01	H0504_043_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	047	0	1	01	01	H0504_047_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	047	0	1	01	01	H0504_047_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	050	0	1	01	01	H0504_050_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	050	0	1	01	01	H0504_050_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	053	0	1	01	01	H0504_053_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	053	0	1	01	01	H0504_053_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	054	0	1	01	01	H0504_054_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	054	0	1	01	01	H0504_054_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	055	0	1	01	01	H0504_055_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	055	0	1	01	01	H0504_055_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	056	0	1	01	01	H0504_056_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	056	0	1	01	01	H0504_056_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0504	057	0	1	01	01	H0504_057_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation  problem focused, comprehensive periodontal evaluation  new or established patient covered once every 36 months from last date of service.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity range: No frequency limit for periodontal maintenance, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	057	0	1	01	01	H0504_057_0	8	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity range: No frequency limit for limited oral evaluation - problem focused, comprehensive periodontal evaluation - new or established patient covered once every 36 months from date of last service rendered.	2				2				2	2	3	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	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	4		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity range:  Periodontal maintenance covered once every 6 months from last date of service, gingivectomy or gingivoplasty  4 or more contiguous teeth or tooth bounded spaces per quadrant covered once every 36 months from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for implant maintenance procedures when prostheses are removed and reinserted including cleansing of protheses and abutments, surgical placement of implant services body, endosteal implant covered once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	1	20	20	20	2				2	2	002
H0524	003	0	1	01	01	H0524_003_0	7	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	008	0	1	01	01	H0524_008_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	013	0	1	01	01	H0524_013_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	015	0	1	01	01	H0524_015_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	031	0	1	01	01	H0524_031_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	032	0	1	01	01	H0524_032_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	033	0	1	01	01	H0524_033_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	034	0	1	01	01	H0524_034_0	7	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	035	0	1	01	01	H0524_035_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	036	0	1	01	01	H0524_036_0	7	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	037	0	1	01	01	H0524_037_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	038	0	1	01	01	H0524_038_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	039	0	1	01	01	H0524_039_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	040	0	1	01	01	H0524_040_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	041	0	1	01	01	H0524_041_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	042	0	1	01	01	H0524_042_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	043	0	1	01	01	H0524_043_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	046	0	1	01	01	H0524_046_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	051	0	1	01	01	H0524_051_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	054	0	1	01	01	H0524_054_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	059	0	1	01	01	H0524_059_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	060	0	1	01	01	H0524_060_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	061	0	1	01	01	H0524_061_0	7	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	062	0	1	01	01	H0524_062_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	063	0	1	01	01	H0524_063_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	064	0	1	01	01	H0524_064_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	065	0	1	01	01	H0524_065_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	078	0	1	01	01	H0524_078_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	081	0	1	01	01	H0524_081_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	082	0	1	01	01	H0524_082_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0524	083	0	1	01	01	H0524_083_0	6	2		2	2				2			2							2	2					2				2					2					2																	3	2	1	6	1 cone beam CT per yr. 1 interpretation per yr.	2				3		0.00	105.00	2	1	3	2	1	2		2				1	0.00	0.00	0.00	2	1																															3	2	1	3		2				1	0.00	0.00	0.00	2	1	2						2					2		3	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	3	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	3	2	1	6	1 gingivectomy or gingivoplasty per quadrant every 3 yrs. 1 gingival flap or osseous surgery per quadrant every 3 yrs. 1 crown lengthening per tooth per lifetime. 1 tissue regeneration every 3 yrs. 1 mouth debridement every 2 yrs.	2				3		0.00	643.00	2	1	3	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	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1	3	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	3	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																3	2	1	6	Palliative treatment limited to 1 visit per day. Anesthesia services governed by time-based allowances. Nitrous limited to 3 per yr; minimal sedation 3 per yr. Diagnostic consult 1 per lifetime per provider. After-hours visit 1 per yr.	2				3		0.00	151.00	2	1	001
H0543	035	0	1	02	01	H0543_035_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	086	0	1	02	01	H0543_086_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	121	0	1	02	01	H0543_121_0	2	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	140	0	1	02	01	H0543_140_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	145	0	1	02	01	H0543_145_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	152	0	1	02	01	H0543_152_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	188	0	1	02	01	H0543_188_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	191	0	1	02	01	H0543_191_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	204	0	1	02	01	H0543_204_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	214	0	1	02	01	H0543_214_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	222	0	1	02	01	H0543_222_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	225	0	1	02	01	H0543_225_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	232	0	1	02	01	H0543_232_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	236	0	1	02	01	H0543_236_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	237	0	1	02	01	H0543_237_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	238	0	1	02	01	H0543_238_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0543	258	0	1	02	01	H0543_258_0	2	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	005	0	1	01	01	H0544_005_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	005	0	1	01	01	H0544_005_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	005	0	1	01	01	H0544_005_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	096	0	1	02	01	H0544_096_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	096	0	1	02	01	H0544_096_0	4	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	096	0	1	02	01	H0544_096_0	4	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0571	001	0	1	01	01	H0571_001_0	6	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2420.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	007	0	1	01	01	H0571_007_0	6	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2420.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	011	0	1	01	01	H0571_011_0	8	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2420.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0609	012	0	1	02	01	H0609_012_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	026	0	1	02	01	H0609_026_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	034	1	1	02	01	H0609_034_1	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	036	1	1	02	01	H0609_036_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	036	2	1	02	01	H0609_036_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	040	0	1	02	01	H0609_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	042	0	1	02	01	H0609_042_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	051	0	1	02	01	H0609_051_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	054	0	1	02	01	H0609_054_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	059	0	1	02	01	H0609_059_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	066	0	1	02	01	H0609_066_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	067	0	1	02	01	H0609_067_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	068	0	1	02	01	H0609_068_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	072	0	1	02	01	H0609_072_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0609	077	0	1	02	01	H0609_077_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0628	007	0	1	02	01	H0628_007_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0628	008	0	1	02	01	H0628_008_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0628	024	0	1	02	01	H0628_024_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	013	0	1	02	01	H0630_013_0	9																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	015	0	1	02	01	H0630_015_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	016	0	1	02	01	H0630_016_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	017	0	1	02	01	H0630_017_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	020	0	1	02	01	H0630_020_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	021	0	1	02	01	H0630_021_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	023	0	1	02	01	H0630_023_0	8								2																																																																																																																										1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0630	025	0	1	02	01	H0630_025_0	8																																																																																																																																		1	2		1000.00	3		2					2																																																																													3	2	1	6	Implant placement, abutments, crowns, and surgical removal limited to 1 every 84 rolling months. Implant-supported prosthetics limited to 1 every 60 rolling months. Retorquing limited to 1 every 24 months.	1	50	50	50	2				2	2																																																													001
H0755	031	0	1	02	01	H0755_031_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	032	0	1	02	01	H0755_032_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	033	0	1	02	01	H0755_033_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	038	0	1	02	01	H0755_038_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	044	0	1	02	01	H0755_044_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	045	0	1	02	01	H0755_045_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0755	047	0	1	02	01	H0755_047_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H0816	001	0	1	02	01	H0816_001_0	10	1	1	1		1	1		1	1	1	1	1		1	1	1		1																																																				3	1				1	50	50	50	2				2	2																																																																																																																																																																																																																	001
H0816	002	0	1	02	01	H0816_002_0	11	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1036	318	0	1	02	01	H1036_318_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	319	0	1	01	01	H1036_319_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	323	0	1	01	01	H1036_323_0	6	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	334	0	1	01	01	H1036_334_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	343	0	1	02	01	H1036_343_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1170	002	0	1	01	01	H1170_002_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	009	0	1	01	01	H1170_009_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	012	0	1	01	01	H1170_012_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	013	0	1	02	01	H1170_013_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	014	0	1	01	01	H1170_014_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	016	0	1	01	01	H1170_016_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1170	017	0	1	01	01	H1170_017_0	5	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	1																																																													2						2					2		3	2	2	6	2 filling procedures per yr; 1 filling per surface per tooth every 2 yrs. Recementation 1 per tooth every 2 yrs; prefab crown 1 per tooth every 2 yrs; pin retention 1 per tooth every 2 yrs; protective restoration 1 per tooth per lifetime.	2				3		7.00	45.00	2	1	3	2	2	6	2 root canal procedures per yr. 1 root canal per tooth per lifetime. Retreatment limited to 1 per tooth every 2 yrs. Pulpotomy or pulpal debridement limited to 1 per tooth per lifetime. Apicoectomy, retrograde filling, and root amputation limited to 1 per tooth per lifetime.	2				3		9.00	250.00	2	1	3	2	1	6	1 gingivectomy/gingival flap per quadrant every 3 yrs; 1 osseous surgery per quadrant every 3 yrs; 1 crown lengthen per tooth per lifetime; 1 tissue regeneration per tooth every 3 yrs; 1 scaling/root planing per quadrant every 2 yrs; 1 debridement every 2 yrs; 1 antimicrobial agent per tooth 2 yrs	2				3		9.00	257.00	2	1	3	2	1	6	Partial dentures 1 per arch every 5 yrs. Repairs, relines, adjustments, and add tooth/clasp limited to 12 per yr depending on service. Rebases 1 every 2 yrs; soft liners up to 2 per yr.	2				3		19.00	171.00	2	1																3	2	2	6	2 implant or abutment procedures per yr and 1 per tooth every 5 yrs. 2 implant-supported crowns/retainers per yr and 1 per tooth every 5 yrs. 1 recementation per arch per yr. 1 implant-supported denture every 5 yrs. 1 index per arch every 5 yrs.	2				3		41.00	2000.00	2	1																3	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		21.00	196.00	2	1																3	2	1	6	Anesthesia limited to 60 mins per date of service (15-min increments; max 3 subsequent units/day). 3 nitrous/minimal sedation per yr. IV sedation subject to daily unit limits. 1 consult per lifetime per provider; 1 after-hours visit per yr; occlusal adjustment every 5 yrs.	2				3		9.00	60.00	2	1	001
H1181	001	0		07	02	H1181_001_0	3																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	3		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H1225	001	0	1	01	01	H1225_001_0	9																																																																																																																																		1	2		1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H1230	001	0	1	01	01	H1230_001_0	7								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	003	0	1	01	01	H1230_003_0	7								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	013	0	1	01	01	H1230_013_0	7								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	014	0	1	01	01	H1230_014_0	7								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1278	003	0	1	04	01	H1278_003_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	010	0	1	04	01	H1278_010_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	015	0	1	04	01	H1278_015_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	016	0	1	04	01	H1278_016_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	020	0	1	04	01	H1278_020_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	024	0	1	04	01	H1278_024_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1278	027	0	1	04	01	H1278_027_0	2	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1350	032	0	1	01	01	H1350_032_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	033	0	1	01	01	H1350_033_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	034	0	1	01	01	H1350_034_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	035	0	1	01	01	H1350_035_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	036	0	1	01	01	H1350_036_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	037	0	1	01	01	H1350_037_0	3																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	004	0	1	02	01	H1423_004_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	004	0	1	02	01	H1423_004_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	004	0	1	02	01	H1423_004_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	005	0	1	02	01	H1423_005_0	5	2	2	2		2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	005	0	1	02	01	H1423_005_0	5	2	2	2		2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	005	0	1	02	01	H1423_005_0	5	2	2	2		2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	007	0	1	01	01	H1423_007_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	007	0	1	01	01	H1423_007_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	007	0	1	01	01	H1423_007_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	012	0	1	04	01	H1607_012_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	012	0	1	04	01	H1607_012_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	012	0	1	04	01	H1607_012_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	015	0	1	04	01	H1607_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	015	0	1	04	01	H1607_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	015	0	1	04	01	H1607_015_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1846	007	0	1	04	01	H1846_007_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	007	0	1	04	01	H1846_007_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1889	013	0	1	04	01	H1889_013_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1889	015	0	1	04	01	H1889_015_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1889	020	0	1	04	01	H1889_020_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1889	025	0	1	04	01	H1889_025_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1961	014	2	1	02	01	H1961_014_2	7	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1961	020	0	1	02	01	H1961_020_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1961	023	0	1	02	01	H1961_023_0	7	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1961	033	1	1	02	01	H1961_033_1	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H1961	033	2	1	02	01	H1961_033_2	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	010	0	1	04	01	H2001_010_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	023	0	1	04	01	H2001_023_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	055	0	1	04	01	H2001_055_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	060	0	1	04	01	H2001_060_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	090	0	1	04	01	H2001_090_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	094	0	1	04	01	H2001_094_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	095	0	1	04	01	H2001_095_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	097	0	1	04	01	H2001_097_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	098	0	1	04	01	H2001_098_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	103	0	1	04	01	H2001_103_0	2	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	104	0	1	04	01	H2001_104_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	108	0	1	04	01	H2001_108_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	110	0	1	04	01	H2001_110_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	116	0	1	04	01	H2001_116_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	117	0	1	04	01	H2001_117_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	119	0	1	04	01	H2001_119_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	125	0	1	04	01	H2001_125_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	127	0	1	04	01	H2001_127_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	128	0	1	04	01	H2001_128_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	131	0	1	04	01	H2001_131_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	133	0	1	04	01	H2001_133_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	135	0	1	04	01	H2001_135_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	146	0	1	04	01	H2001_146_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	147	0	1	04	01	H2001_147_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2001	153	0	1	04	01	H2001_153_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2032	001	0	1	04	01	H2032_001_0	10																																																																																																																																		1	2	2	2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H2032	002	0	1	04	01	H2032_002_0	10																																																																																																																																		1	2	2	2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H2032	003	0	1	04	01	H2032_003_0	11																																																																																																																																		1	2	2	2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H2172	001	0	1	02	01	H2172_001_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	001	0	1	02	01	H2172_001_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	002	0	1	02	01	H2172_002_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	002	0	1	02	01	H2172_002_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	005	0	1	01	01	H2172_005_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	005	0	1	01	01	H2172_005_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	008	0	1	02	01	H2172_008_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	008	0	1	02	01	H2172_008_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	009	0	1	02	01	H2172_009_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	009	0	1	02	01	H2172_009_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	010	0	1	02	01	H2172_010_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	010	0	1	02	01	H2172_010_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	013	0	1	02	01	H2172_013_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	013	0	1	02	01	H2172_013_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	014	0	1	02	01	H2172_014_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	014	0	1	02	01	H2172_014_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	020	0	1	02	01	H2172_020_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	020	0	1	02	01	H2172_020_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	021	0	1	02	01	H2172_021_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	021	0	1	02	01	H2172_021_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	022	0	1	02	01	H2172_022_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	022	0	1	02	01	H2172_022_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	023	0	1	02	01	H2172_023_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	023	0	1	02	01	H2172_023_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	024	0	1	02	01	H2172_024_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	024	0	1	02	01	H2172_024_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	025	0	1	01	01	H2172_025_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	025	0	1	01	01	H2172_025_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	026	0	1	01	01	H2172_026_0	6																																																																																																																																		1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	026	0	1	01	01	H2172_026_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	027	0	1	02	01	H2172_027_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	027	0	1	02	01	H2172_027_0	6								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2256	001	1	1	01	01	H2256_001_1	8																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	2	1	01	01	H2256_001_2	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	6	1	01	01	H2256_001_6	8																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	1	1	01	01	H2256_015_1	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	2	1	01	01	H2256_015_2	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	6	1	01	01	H2256_015_6	8																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	1	1	01	01	H2256_016_1	4																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	2	1	01	01	H2256_016_2	4																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	1	1	01	01	H2256_018_1	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	7	1	01	01	H2256_018_7	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	8	1	01	01	H2256_018_8	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	1	1	01	01	H2256_019_1	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	7	1	01	01	H2256_019_7	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	1	1	01	01	H2256_026_1	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	2	1	01	01	H2256_026_2	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	3	1	01	01	H2256_026_3	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	033	0	1	01	01	H2256_033_0	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	034	0	1	01	01	H2256_034_0	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	036	0	1	01	01	H2256_036_0	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	039	0	1	01	01	H2256_039_0	4																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	040	0	1	01	01	H2256_040_0	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	041	0	1	01	01	H2256_041_0	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	042	0	1	01	01	H2256_042_0	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2320	022	1	1	02	01	H2320_022_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	022	1	1	02	01	H2320_022_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	022	2	1	02	01	H2320_022_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	022	2	1	02	01	H2320_022_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	022	5	1	02	01	H2320_022_5	4	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	022	5	1	02	01	H2320_022_5	4	2		2		2			2			2					2			2					2				2					2					2																	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	028	1	1	02	01	H2320_028_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	028	1	1	02	01	H2320_028_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	028	2	1	02	01	H2320_028_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	028	2	1	02	01	H2320_028_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	028	3	1	02	01	H2320_028_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	028	3	1	02	01	H2320_028_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	028	4	1	02	01	H2320_028_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	028	4	1	02	01	H2320_028_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	028	5	1	02	01	H2320_028_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	028	5	1	02	01	H2320_028_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	029	1	1	02	01	H2320_029_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	029	1	1	02	01	H2320_029_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	1	50	50	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	029	2	1	02	01	H2320_029_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	029	2	1	02	01	H2320_029_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	1	50	50	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	029	3	1	02	01	H2320_029_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	029	3	1	02	01	H2320_029_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	1	50	50	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	029	4	1	02	01	H2320_029_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	029	4	1	02	01	H2320_029_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	1	50	50	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	029	5	1	02	01	H2320_029_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	029	5	1	02	01	H2320_029_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	1	50	50	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	032	1	1	02	01	H2320_032_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	032	1	1	02	01	H2320_032_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	032	2	1	02	01	H2320_032_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	032	2	1	02	01	H2320_032_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	032	5	1	02	01	H2320_032_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	032	5	1	02	01	H2320_032_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	033	1	1	02	01	H2320_033_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H2320	033	1	1	02	01	H2320_033_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H2320	033	2	1	02	01	H2320_033_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H2320	033	2	1	02	01	H2320_033_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H2320	033	5	1	02	01	H2320_033_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H2320	033	5	1	02	01	H2320_033_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H2320	034	3	1	02	01	H2320_034_3	6	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	034	3	1	02	01	H2320_034_3	6	2		2		2			2			2					2			2					2				2					2					2																	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2320	034	4	1	02	01	H2320_034_4	6	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2		2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H2320	034	4	1	02	01	H2320_034_4	6	2		2		2			2			2					2			2					2				2					2					2																	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2		1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H2322	008	0	1	04	01	H2322_008_0	7	2		2					2	2		2								1	2	2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2		3	2	1	2		1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2322	011	0	1	04	01	H2322_011_0	7	2		2					2	2		2								1	2	2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2322	016	0	1	04	01	H2322_016_0	7	2		2					2	2		2								1	2	2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2322	017	0	1	04	01	H2322_017_0	7	2		2					2	2		2								1	2	2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	015	0	1	01	01	H2354_015_0	7	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	018	0	1	01	01	H2354_018_0	8	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	019	0	1	01	01	H2354_019_0	6	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	021	0	1	02	01	H2354_021_0	8	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	028	0	1	01	01	H2354_028_0	7	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2354	029	0	1	01	01	H2354_029_0	7	2		2					2			2								1		2000.00	3		2				2					2					2																	3	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	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H2406	039	0	1	04	01	H2406_039_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	040	0	1	04	01	H2406_040_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	041	0	1	04	01	H2406_041_0	2	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	043	0	1	04	01	H2406_043_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	044	0	1	04	01	H2406_044_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	048	0	1	04	01	H2406_048_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	056	0	1	04	01	H2406_056_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	059	0	1	04	01	H2406_059_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	062	0	1	04	01	H2406_062_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	065	0	1	04	01	H2406_065_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	066	0	1	04	01	H2406_066_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	068	0	1	04	01	H2406_068_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	070	0	1	04	01	H2406_070_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	071	0	1	04	01	H2406_071_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	072	0	1	04	01	H2406_072_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	075	0	1	04	01	H2406_075_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	076	0	1	04	01	H2406_076_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	078	0	1	04	01	H2406_078_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	082	0	1	04	01	H2406_082_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	087	0	1	04	01	H2406_087_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	088	0	1	04	01	H2406_088_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	089	0	1	04	01	H2406_089_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	091	0	1	04	01	H2406_091_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	094	0	1	04	01	H2406_094_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	096	0	1	04	01	H2406_096_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	097	0	1	04	01	H2406_097_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	098	0	1	04	01	H2406_098_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	101	0	1	04	01	H2406_101_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	119	0	1	04	01	H2406_119_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2406	142	0	1	04	01	H2406_142_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2462	027	0	1	18	06	H2462_027_0	3																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2462	028	0	1	18	06	H2462_028_0	2																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	001	0	1	02	01	H2593_001_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	001	0	1	02	01	H2593_001_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	001	0	1	02	01	H2593_001_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	003	0	1	01	01	H2593_003_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	003	0	1	01	01	H2593_003_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	003	0	1	01	01	H2593_003_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	029	0	1	02	01	H2593_029_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	029	0	1	02	01	H2593_029_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	029	0	1	02	01	H2593_029_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	043	0	1	02	01	H2593_043_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	043	0	1	02	01	H2593_043_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	043	0	1	02	01	H2593_043_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2802	001	0	1	02	01	H2802_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	007	0	1	02	01	H2802_007_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	008	0	1	02	01	H2802_008_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	010	0	1	02	01	H2802_010_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	028	0	1	02	01	H2802_028_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	030	0	1	02	01	H2802_030_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	048	0	1	02	01	H2802_048_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	049	0	1	02	01	H2802_049_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	054	0	1	02	01	H2802_054_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	059	0	1	02	01	H2802_059_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	060	0	1	02	01	H2802_060_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	063	0	1	02	01	H2802_063_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	068	0	1	02	01	H2802_068_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	070	0	1	02	01	H2802_070_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	071	0	1	02	01	H2802_071_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	076	0	1	02	01	H2802_076_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H2802	088	0	1	02	01	H2802_088_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3152	048	0	1	01	01	H3152_048_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3152	082	0	1	01	01	H3152_082_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3152	098	0	1	01	01	H3152_098_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3186	001	0	1	04	01	H3186_001_0	11	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3186	002	0	1	04	01	H3186_002_0	11	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3192	005	0	1	02	01	H3192_005_0	4																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3192	020	0	1	02	01	H3192_020_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3240	026	0	1	01	01	H3240_026_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3240	026	0	1	01	01	H3240_026_0	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3240	026	0	1	01	01	H3240_026_0	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3312	002	0	1	01	01	H3312_002_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	048	0	1	01	01	H3312_048_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	064	0	1	01	01	H3312_064_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	074	0	1	01	01	H3312_074_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	081	0	1	01	01	H3312_081_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	097	0	1	01	01	H3312_097_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	107	0	1	01	01	H3312_107_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	108	0	1	01	01	H3312_108_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3312	113	0	1	01	01	H3312_113_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3351	001	0	1	02	01	H3351_001_0	5								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	002	0	1	02	01	H3351_002_0	6								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	006	0	1	02	01	H3351_006_0	6								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	007	0	1	02	01	H3351_007_0	4																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	012	0	1	02	01	H3351_012_0	6								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	017	0	1	01	01	H3351_017_0	6								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	019	0	1	02	01	H3351_019_0	6								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	022	0	1	01	01	H3351_022_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	023	0	1	02	01	H3351_023_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	024	0	1	01	01	H3351_024_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	025	0	1	02	01	H3351_025_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	026	0	1	02	01	H3351_026_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	027	0	1	02	01	H3351_027_0	4																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	028	0	1	01	01	H3351_028_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	029	0	1	02	01	H3351_029_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	030	0	1	02	01	H3351_030_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	031	0	1	02	01	H3351_031_0	4																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	032	0	1	02	01	H3351_032_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	033	0	1	02	01	H3351_033_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3379	001	0	1	02	01	H3379_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3379	054	0	1	02	01	H3379_054_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3379	059	0	1	02	01	H3379_059_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3379	061	0	1	02	01	H3379_061_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3418	001	0	1	04	01	H3418_001_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3418	002	0	1	04	01	H3418_002_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3418	004	0	1	04	01	H3418_004_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3418	008	0	1	04	01	H3418_008_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3443	005	0	1	01	01	H3443_005_0	9	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3447	013	0	1	02	01	H3447_013_0	4	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	013	0	1	02	01	H3447_013_0	4	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	013	0	1	02	01	H3447_013_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	025	0	1	02	01	H3447_025_0	4	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	025	0	1	02	01	H3447_025_0	4	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	025	0	1	02	01	H3447_025_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	033	0	1	02	01	H3447_033_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	033	0	1	02	01	H3447_033_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	033	0	1	02	01	H3447_033_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	037	0	1	02	01	H3447_037_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	037	0	1	02	01	H3447_037_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	037	0	1	02	01	H3447_037_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	1	1	02	01	H3447_038_1	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	1	1	02	01	H3447_038_1	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	1	1	02	01	H3447_038_1	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	039	0	1	02	01	H3447_039_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	039	0	1	02	01	H3447_039_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	039	0	1	02	01	H3447_039_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	1	1	02	01	H3447_042_1	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	1	1	02	01	H3447_042_1	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	1	1	02	01	H3447_042_1	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	2	1	02	01	H3447_042_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	2	1	02	01	H3447_042_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	2	1	02	01	H3447_042_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	4	1	02	01	H3447_042_4	4	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	4	1	02	01	H3447_042_4	4	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	4	1	02	01	H3447_042_4	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	049	0	1	02	01	H3447_049_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	049	0	1	02	01	H3447_049_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	049	0	1	02	01	H3447_049_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	050	0	1	02	01	H3447_050_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	050	0	1	02	01	H3447_050_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	050	0	1	02	01	H3447_050_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	051	0	1	02	01	H3447_051_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	051	0	1	02	01	H3447_051_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	051	0	1	02	01	H3447_051_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	052	0	1	02	01	H3447_052_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	052	0	1	02	01	H3447_052_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	052	0	1	02	01	H3447_052_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	056	0	1	02	01	H3447_056_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	056	0	1	02	01	H3447_056_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	056	0	1	02	01	H3447_056_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	001	1	1	02	01	H3529_001_1	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	001	1	1	02	01	H3529_001_1	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	001	1	1	02	01	H3529_001_1	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	001	2	1	02	01	H3529_001_2	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	001	2	1	02	01	H3529_001_2	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	001	2	1	02	01	H3529_001_2	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	001	3	1	02	01	H3529_001_3	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	001	3	1	02	01	H3529_001_3	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	001	3	1	02	01	H3529_001_3	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	001	4	1	02	01	H3529_001_4	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	001	4	1	02	01	H3529_001_4	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	001	4	1	02	01	H3529_001_4	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	002	1	1	02	01	H3529_002_1	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	002	1	1	02	01	H3529_002_1	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	002	1	1	02	01	H3529_002_1	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	002	2	1	02	01	H3529_002_2	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	002	2	1	02	01	H3529_002_2	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	002	2	1	02	01	H3529_002_2	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	002	3	1	02	01	H3529_002_3	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	002	3	1	02	01	H3529_002_3	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	002	3	1	02	01	H3529_002_3	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3529	002	4	1	02	01	H3529_002_4	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3529	002	4	1	02	01	H3529_002_4	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3529	002	4	1	02	01	H3529_002_4	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3533	033	0	1	01	01	H3533_033_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	4	1	02	01	H3655_045_4	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	4	1	02	01	H3655_045_4	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	4	1	02	01	H3655_045_4	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3660	028	0	1	02	01	H3660_028_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	029	0	1	02	01	H3660_029_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	044	0	1	01	01	H3660_044_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	050	0	1	01	01	H3660_050_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	057	0	1	01	01	H3660_057_0	12								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	058	0	1	01	01	H3660_058_0	8								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period, once per 5-year period or once per lifetime.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	1	1	01	01	H3668_018_1	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	1	1	01	01	H3668_018_1	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	2	1	01	01	H3668_018_2	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	2	1	01	01	H3668_018_2	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	2	1	01	01	H3668_019_2	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	2	1	01	01	H3668_019_2	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	025	0	1	01	01	H3668_025_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	025	0	1	01	01	H3668_025_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	026	0	1	01	01	H3668_026_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	026	0	1	01	01	H3668_026_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	029	0	1	01	01	H3668_029_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	029	0	1	01	01	H3668_029_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3672	013	0	1	01	01	H3672_013_0	6								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	014	0	1	01	01	H3672_014_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	020	0	1	01	01	H3672_020_0	6								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	021	0	1	01	01	H3672_021_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3805	015	0	1	02	01	H3805_015_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3805	017	0	1	02	01	H3805_017_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3805	032	0	1	02	01	H3805_032_0	3	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3805	033	0	1	02	01	H3805_033_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3805	040	0	1	02	01	H3805_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3805	048	0	1	02	01	H3805_048_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H3815	001	0	1	01	01	H3815_001_0	12	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	008	0	1	01	01	H3815_008_0	13	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	010	0	1	01	01	H3815_010_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	011	0	1	01	01	H3815_011_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	013	0	1	01	01	H3815_013_0	12	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	019	0	1	01	01	H3815_019_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	020	0	1	01	01	H3815_020_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	021	0	1	01	01	H3815_021_0	8	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	023	0	1	01	01	H3815_023_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	028	0	1	01	01	H3815_028_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	031	0	1	01	01	H3815_031_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	033	0	1	01	01	H3815_033_0	9	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	035	0	1	01	01	H3815_035_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	038	0	1	01	01	H3815_038_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	040	0	1	01	01	H3815_040_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	047	0	1	01	01	H3815_047_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	048	0	1	01	01	H3815_048_0	11	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	054	0	1	01	01	H3815_054_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	055	0	1	01	01	H3815_055_0	11	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	056	0	1	01	01	H3815_056_0	10	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	061	0	1	01	01	H3815_061_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3822	001	0	1	02	01	H3822_001_0	7	1	1	1	1	1			2	2		2			2		2		2																																																																																																																2						2					2		3	1				3		0	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		0	50	2				2	2	001
H3822	002	0	1	02	01	H3822_002_0	7	1	1	1	1	1			2	2		2			2		2		2																																																																																																																2						2					2		3	1				3		0	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		0	50	2				2	2	001
H3822	019	0	1	02	01	H3822_019_0	7	1	1	1	1	1			2	2		2			2		2		2																																																																																																																2						2					2		3	1				3		0	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				3		0	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		0	50	2				2	2	001
H3890	001	0	1	04	01	H3890_001_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H3890	002	0	1	04	01	H3890_002_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for benefit details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H3924	059	21	1	04	01	H3924_059_21	5																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	059	22	1	04	01	H3924_059_22	5																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	065	0	1	04	01	H3924_065_0	5																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	4	2	2	2		2	2													1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	4	2	2	2		2	2													1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	008	0	1	04	01	H4036_008_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	022	0	1	04	01	H4036_022_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	022	0	1	04	01	H4036_022_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	022	0	1	04	01	H4036_022_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4141	022	0	1	01	01	H4141_022_0	6	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	004	0	1	02	01	H4161_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	004	0	1	02	01	H4161_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	004	0	1	02	01	H4161_004_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	005	0	1	02	01	H4161_005_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	005	0	1	02	01	H4161_005_0	4	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	005	0	1	02	01	H4161_005_0	4	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	006	0	1	02	01	H4161_006_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	006	0	1	02	01	H4161_006_0	4	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	006	0	1	02	01	H4161_006_0	4	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	007	0	1	02	01	H4161_007_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	007	0	1	02	01	H4161_007_0	4	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	007	0	1	02	01	H4161_007_0	4	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	012	0	1	02	01	H4161_012_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	012	0	1	02	01	H4161_012_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	012	0	1	02	01	H4161_012_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	013	0	1	02	01	H4161_013_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	013	0	1	02	01	H4161_013_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	013	0	1	02	01	H4161_013_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	014	0	1	02	01	H4161_014_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	014	0	1	02	01	H4161_014_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	014	0	1	02	01	H4161_014_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	015	0	1	02	01	H4161_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	015	0	1	02	01	H4161_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	015	0	1	02	01	H4161_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	016	0	1	02	01	H4161_016_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	016	0	1	02	01	H4161_016_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	016	0	1	02	01	H4161_016_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	017	0	1	02	01	H4161_017_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	017	0	1	02	01	H4161_017_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	017	0	1	02	01	H4161_017_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	001	0	1	02	01	H4346_001_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	001	0	1	02	01	H4346_001_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	001	0	1	02	01	H4346_001_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	005	0	1	02	01	H4346_005_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	005	0	1	02	01	H4346_005_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	005	0	1	02	01	H4346_005_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	006	0	1	02	01	H4346_006_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	006	0	1	02	01	H4346_006_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	006	0	1	02	01	H4346_006_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	010	0	1	01	01	H4346_010_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	010	0	1	01	01	H4346_010_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	010	0	1	01	01	H4346_010_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	012	0	1	02	01	H4346_012_0	4	2	2	2		2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	012	0	1	02	01	H4346_012_0	4	2	2	2		2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	012	0	1	02	01	H4346_012_0	4	2	2	2		2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	017	0	1	02	01	H4346_017_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	017	0	1	02	01	H4346_017_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	017	0	1	02	01	H4346_017_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	037	0	1	02	01	H4346_037_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	037	0	1	02	01	H4346_037_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	037	0	1	02	01	H4346_037_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4497	001	1	1	04	01	H4497_001_1	8																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	001	3	1	04	01	H4497_001_3	8																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	1	1	04	01	H4497_002_1	8																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	3	1	04	01	H4497_002_3	8																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4514	007	0	1	02	01	H4514_007_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	001	0	1	02	01	H4527_001_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	002	0	1	02	01	H4527_002_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	024	0	1	02	01	H4527_024_0	2	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	037	0	1	02	01	H4527_037_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	039	0	1	02	01	H4527_039_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	048	0	1	02	01	H4527_048_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	051	0	1	02	01	H4527_051_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4527	053	0	1	02	01	H4527_053_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	011	0	1	02	01	H4604_011_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	016	0	1	02	01	H4604_016_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	017	0	1	02	01	H4604_017_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	020	0	1	02	01	H4604_020_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	022	0	1	02	01	H4604_022_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	024	0	1	02	01	H4604_024_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	025	0	1	02	01	H4604_025_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	027	0	1	02	01	H4604_027_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4604	034	0	1	02	01	H4604_034_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H4875	016	1	1	04	01	H4875_016_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H4875	016	1	1	04	01	H4875_016_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H4875	016	2	1	04	01	H4875_016_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H4875	016	2	1	04	01	H4875_016_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H4875	016	3	1	04	01	H4875_016_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H4875	016	3	1	04	01	H4875_016_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H4875	016	4	1	04	01	H4875_016_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H4875	016	4	1	04	01	H4875_016_4	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H4875	016	5	1	04	01	H4875_016_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	001
H4875	016	5	1	04	01	H4875_016_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H4875	018	1	1	04	01	H4875_018_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	018	1	1	04	01	H4875_018_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	018	2	1	04	01	H4875_018_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	018	2	1	04	01	H4875_018_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	018	5	1	04	01	H4875_018_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	018	5	1	04	01	H4875_018_5	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	020	1	1	04	01	H4875_020_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	020	1	1	04	01	H4875_020_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	020	2	1	04	01	H4875_020_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	020	2	1	04	01	H4875_020_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	020	3	1	04	01	H4875_020_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	020	3	1	04	01	H4875_020_3	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	024	1	1	04	01	H4875_024_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	024	1	1	04	01	H4875_024_1	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	024	2	1	04	01	H4875_024_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	024	2	1	04	01	H4875_024_2	3	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4875	024	5	1	04	01	H4875_024_5	4	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	50	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H4875	024	5	1	04	01	H4875_024_5	4	2		2		2			2			2					2			2					2				2					2					2																	3	1				1	25	25	25	2				2	2																3	2	1	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	Services are covered every 12 months, 2 years or 60 months. Full description in notes.	1	25	25	25	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	25	25	25	2				2	2	3	2	1	6	Cleanings, surgical and non-surgical procedures are covered. See note below.	3		0	25	2				2	2	3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	25	25	25	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	25	25	25	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime	1	25	25	25	2				2	2																3	1				3		0	25	2				2	2	002
H4882	015	0	1	04	01	H4882_015_0	6	2	2	2		2		2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	016	0	1	04	01	H4882_016_0	5	2	2	2		2		2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	017	0	1	04	01	H4882_017_0	5	2	2	2		2		2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	018	0	1	04	01	H4882_018_0	6	2	2	2		2		2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	014	0	1	04	01	H4909_014_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	020	0	1	04	01	H4909_020_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	020	0	1	04	01	H4909_020_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	020	0	1	04	01	H4909_020_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	021	0	1	04	01	H4909_021_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	021	0	1	04	01	H4909_021_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	021	0	1	04	01	H4909_021_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	026	0	1	04	01	H4909_026_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	026	0	1	04	01	H4909_026_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	026	0	1	04	01	H4909_026_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4961	001	0	1	04	01	H4961_001_0	11	2	2	2		2	2													1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	006	0	1	04	01	H4961_006_0	10	2	2	2		2	2													1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	802	0	1	04	01	H4961_802_0	3																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5050	001	0	1	01	01	H5050_001_0	7	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	004	0	1	01	01	H5050_004_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	009	0	1	01	01	H5050_009_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	019	0	1	01	01	H5050_019_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	021	0	1	01	01	H5050_021_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	024	0	1	01	01	H5050_024_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	025	0	1	01	01	H5050_025_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	026	0	1	01	01	H5050_026_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	027	0	1	01	01	H5050_027_0	8	2	2	2					2										2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2																															3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Anesthesia and sedation, not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	1	50	50	50	2				2	2	001
H5050	028	0	1	01	01	H5050_028_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Comprehensive and panoramic images limited to 1 per 3 yrs. Bitewings 2 per yr; single bitewings not subject to frequency limits. Periapical and occlusal X-rays not subject to frequency limits.	2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Palliative treatment, anesthesia and sedation services, treatment of complications, denture cleaning, and fixed partial denture sectioning not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	3		0	50	2				2	2	001
H5050	029	0	1	01	01	H5050_029_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Comprehensive and panoramic images limited to 1 per 3 yrs. Bitewings 2 per yr; single bitewings not subject to frequency limits. Periapical and occlusal X-rays not subject to frequency limits.	2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Palliative treatment, anesthesia and sedation services, treatment of complications, denture cleaning, and fixed partial denture sectioning not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	3		0	50	2				2	2	001
H5050	030	0	1	01	01	H5050_030_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Comprehensive and panoramic images limited to 1 per 3 yrs. Bitewings 2 per yr; single bitewings not subject to frequency limits. Periapical and occlusal X-rays not subject to frequency limits.	2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Palliative treatment, anesthesia and sedation services, treatment of complications, denture cleaning, and fixed partial denture sectioning not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	3		0	50	2				2	2	001
H5050	031	0	1	01	01	H5050_031_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Comprehensive and panoramic images limited to 1 per 3 yrs. Bitewings 2 per yr; single bitewings not subject to frequency limits. Periapical and occlusal X-rays not subject to frequency limits.	2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Palliative treatment, anesthesia and sedation services, treatment of complications, denture cleaning, and fixed partial denture sectioning not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	3		0	50	2				2	2	001
H5050	032	0	1	01	01	H5050_032_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Comprehensive and panoramic images limited to 1 per 3 yrs. Bitewings 2 per yr; single bitewings not subject to frequency limits. Periapical and occlusal X-rays not subject to frequency limits.	2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	2	1	6	Fillings 1 per surface per tooth every 2 yrs. Inlays 1 per 2 yrs; onlays and crowns 1 per 5 yrs. Re-cementation 1 per 12 months. Protective restorations 1 per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Endodontic therapy not subject to frequency limits. Retreatment and certain surgical procedures 1 every 2 yrs. Graft and regeneration procedures 1 every 3 yrs.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing 1 per quadrant per year. Periodontal maintenance and gingival inflammation procedures 2 per year. Full mouth debridement 1 per year. Surgical procedures not subject to frequency limits.	3		0	50	2				2	2	3	2	1	6	Complete and partial dentures 1 per 5 years. Rebases and relines 1 per 12 months. Tissue conditioning 2 per 36 months. Interim dentures 1 per lifetime. Adjustments and repairs not subject to frequency limits.	1	50	50	50	2				2	2																															3	2	1	6	Fixed prosthetics, including crowns, pontics, and retainers 1 per 5 years. Re-cementation 1 per 12 months. Repairs and interim services not subject to frequency limits.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	2	1	6	Palliative treatment, anesthesia and sedation services, treatment of complications, denture cleaning, and fixed partial denture sectioning not subject to frequency limits. Occlusal adjustment limited to 1 per 12 months. Temporary aesthetic appliance limited to 1 per lifetime.	3		0	50	2				2	2	001
H5211	003	0	1	01	01	H5211_003_0	6	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5211	004	0	1	02	01	H5211_004_0	8	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5211	012	0	1	01	01	H5211_012_0	8	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5211	014	0	1	02	01	H5211_014_0	8	1	1	1		1	1		1	1	1	1	1		1	1	1		1																																																				3	1				1	50	50	50	2				2	2																																																																																																																																																																																																																	001
H5211	015	0	1	02	01	H5211_015_0	8	1	1	1		1	1		1	1	1	1	1		1	1	1		1																																																				3	1				1	50	50	50	2				2	2																																																																																																																																																																																																																	001
H5215	002	0	1	04	01	H5215_002_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	3		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	005	0	1	04	01	H5215_005_0	5	2	2			2	2													2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	3		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	008	0	1	04	01	H5215_008_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	3		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	009	0	1	04	01	H5215_009_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	3		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5216	013	0	1	04	01	H5216_013_0	4	2	2	2		2			2	2		2							2	1	2	750.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	017	0	1	04	01	H5216_017_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	019	0	1	04	01	H5216_019_0	6	2	2	2		2			2	2		2							2	1	2	750.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	027	0	1	04	01	H5216_027_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	034	0	1	04	01	H5216_034_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	048	0	1	04	01	H5216_048_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	064	0	1	04	01	H5216_064_0	5	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	1	1	04	01	H5216_078_1	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	6	1	04	01	H5216_078_6	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	089	0	1	04	01	H5216_089_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	100	0	1	04	01	H5216_100_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	116	0	1	04	01	H5216_116_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	120	0	1	04	01	H5216_120_0	5	2	2	2		2			2	2		2							2	1	2	250.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	138	0	1	04	01	H5216_138_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	144	0	1	04	01	H5216_144_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	154	0	1	04	01	H5216_154_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	168	0	1	04	01	H5216_168_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	192	0	1	04	01	H5216_192_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	194	0	1	04	01	H5216_194_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	211	0	1	04	01	H5216_211_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	234	0	1	04	01	H5216_234_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	286	0	1	04	01	H5216_286_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	289	0	1	04	01	H5216_289_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	306	0	1	04	01	H5216_306_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	314	0	1	04	01	H5216_314_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	322	0	1	04	01	H5216_322_0	7	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	327	0	1	04	01	H5216_327_0	4	2	2	2		2			2	2		2							2	1	2	750.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	328	0	1	04	01	H5216_328_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	343	0	1	04	01	H5216_343_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	345	0	1	04	01	H5216_345_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	376	0	1	04	01	H5216_376_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	383	0	1	04	01	H5216_383_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	406	0	1	04	01	H5216_406_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	428	2	1	04	01	H5216_428_2	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	430	0	1	04	01	H5216_430_0	6	2	2	2		2			2	2		2							2	1	2	250.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	433	0	1	04	01	H5216_433_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	442	0	1	04	01	H5216_442_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	461	0	1	04	01	H5216_461_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	464	0	1	04	01	H5216_464_0	6	2	2	2		2			2	2		2							2	1	2	750.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	465	0	1	04	01	H5216_465_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	466	0	1	04	01	H5216_466_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	474	0	1	04	01	H5216_474_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	476	0	1	04	01	H5216_476_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	477	0	1	04	01	H5216_477_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	478	0	1	04	01	H5216_478_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	481	1	1	04	01	H5216_481_1	6	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	481	2	1	04	01	H5216_481_2	6	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5253	034	0	1	02	01	H5253_034_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	035	0	1	02	01	H5253_035_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	039	0	1	02	01	H5253_039_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	062	0	1	02	01	H5253_062_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	072	0	1	02	01	H5253_072_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	089	0	1	02	01	H5253_089_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	099	0	1	02	01	H5253_099_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	103	0	1	02	01	H5253_103_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	110	0	1	02	01	H5253_110_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	119	0	1	02	01	H5253_119_0	3	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	125	1	1	02	01	H5253_125_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	127	0	1	02	01	H5253_127_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	135	0	1	02	01	H5253_135_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	141	0	1	02	01	H5253_141_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	142	0	1	02	01	H5253_142_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	144	1	1	02	01	H5253_144_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	144	2	1	02	01	H5253_144_2	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	150	0	1	02	01	H5253_150_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	154	0	1	02	01	H5253_154_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	155	0	1	02	01	H5253_155_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	157	1	1	02	01	H5253_157_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	157	2	1	02	01	H5253_157_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	161	0	1	02	01	H5253_161_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	162	1	1	02	01	H5253_162_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	162	2	1	02	01	H5253_162_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	173	0	1	02	01	H5253_173_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	175	0	1	02	01	H5253_175_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	183	0	1	02	01	H5253_183_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	185	0	1	02	01	H5253_185_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	186	0	1	02	01	H5253_186_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	188	0	1	02	01	H5253_188_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	189	0	1	02	01	H5253_189_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	193	1	1	02	01	H5253_193_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	202	0	1	02	01	H5253_202_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	207	0	1	02	01	H5253_207_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	214	0	1	02	01	H5253_214_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	222	0	1	02	01	H5253_222_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	243	1	1	02	01	H5253_243_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5253	243	2	1	02	01	H5253_243_2	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5262	001	0	1	01	01	H5262_001_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	003	0	1	01	01	H5262_003_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	004	0	1	01	01	H5262_004_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	005	0	1	01	01	H5262_005_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	007	0	1	01	01	H5262_007_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	008	0	1	01	01	H5262_008_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	009	0	1	01	01	H5262_009_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	010	0	1	01	01	H5262_010_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	021	0	1	01	01	H5262_021_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	023	0	1	01	01	H5262_023_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	032	0	1	01	01	H5262_032_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H5262	033	0	1	01	01	H5262_033_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H5296	006	0	1	01	01	H5296_006_0	9	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5296	008	0	1	01	01	H5296_008_0	11	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5296	013	0	1	01	01	H5296_013_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5322	040	0	1	02	01	H5322_040_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5322	043	0	1	02	01	H5322_043_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5322	053	0	1	02	01	H5322_053_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5422	014	0	1	02	01	H5422_014_0	3	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	014	0	1	02	01	H5422_014_0	3	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	014	0	1	02	01	H5422_014_0	3	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	020	0	1	02	01	H5422_020_0	4	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	020	0	1	02	01	H5422_020_0	4	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	020	0	1	02	01	H5422_020_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5425	001	0	1	01	01	H5425_001_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	005	0	1	01	01	H5425_005_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	006	0	1	01	01	H5425_006_0	13	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	007	0	1	01	01	H5425_007_0	11	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	008	0	1	01	01	H5425_008_0	11	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	009	0	1	01	01	H5425_009_0	11	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	034	0	1	01	01	H5425_034_0	11	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	082	0	1	01	01	H5425_082_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	086	0	1	01	01	H5425_086_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	087	0	1	01	01	H5425_087_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	091	0	1	02	01	H5425_091_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	104	0	1	01	01	H5425_104_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	105	0	1	01	01	H5425_105_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	124	0	1	01	01	H5425_124_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	125	0	1	01	01	H5425_125_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	126	0	1	01	01	H5425_126_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	127	0	1	01	01	H5425_127_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	134	0	1	01	01	H5425_134_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	147	0	1	01	01	H5425_147_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	148	0	1	01	01	H5425_148_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	151	0	1	01	01	H5425_151_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	158	0	1	01	01	H5425_158_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	159	0	1	01	01	H5425_159_0	10	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5472	003	0	1	02	01	H5472_003_0	11	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5472	010	0	1	02	01	H5472_010_0	12	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5472	012	0	1	02	01	H5472_012_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5521	077	0	1	04	01	H5521_077_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	099	0	1	04	01	H5521_099_0	3																																																																																																																																		1	2	2	750.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	120	0	1	04	01	H5521_120_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	121	0	1	04	01	H5521_121_0	5																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	123	0	1	04	01	H5521_123_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	124	0	1	04	01	H5521_124_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	157	0	1	04	01	H5521_157_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	207	0	1	04	01	H5521_207_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	215	0	1	04	01	H5521_215_0	4																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	231	0	1	04	01	H5521_231_0	3																																																																																																																																		1	2	2	750.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	250	0	1	04	01	H5521_250_0	4																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	275	0	1	04	01	H5521_275_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	277	0	1	04	01	H5521_277_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	392	0	1	04	01	H5521_392_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	457	0	1	04	01	H5521_457_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	512	0	1	04	01	H5521_512_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	520	0	1	04	01	H5521_520_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	521	0	1	04	01	H5521_521_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	536	0	1	04	01	H5521_536_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	661	0	1	04	01	H5521_661_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5521	736	0	1	04	01	H5521_736_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5525	004	0	1	04	01	H5525_004_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	006	0	1	04	01	H5525_006_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	008	0	1	04	01	H5525_008_0	4	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	030	0	1	04	01	H5525_030_0	6	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	035	0	1	04	01	H5525_035_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	042	0	1	04	01	H5525_042_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	049	0	1	04	01	H5525_049_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	054	0	1	04	01	H5525_054_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	065	0	1	04	01	H5525_065_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	075	0	1	04	01	H5525_075_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	1	1	04	01	H5525_085_1	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	2	1	04	01	H5525_085_2	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5591	018	0	1	01	01	H5591_018_0	6																			1		1500.00	3		2				2					1	110100	50.00	50.00	50.00	2		3	2	2	3		2								2	2	3	2	1	3		2								2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	2	2	3		2								2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															001
H5591	019	0	1	01	01	H5591_019_0	6																			1		1500.00	3		2				2					1	110100	50.00	50.00	50.00	2		3	2	2	3		2								2	2	3	2	1	3		2								2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	2	2	3		2								2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															001
H5591	020	0	1	01	01	H5591_020_0	5																			1		1500.00	3		2				2					1	110100	50.00	50.00	50.00	2		3	2	2	3		2								2	2	3	2	1	3		2								2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	2	2	3		2								2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															001
H5619	001	0	1	01	01	H5619_001_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	026	0	1	01	01	H5619_026_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	061	0	1	01	01	H5619_061_0	4	2	2	2		2			2	2		2							2	1		500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	066	0	1	01	01	H5619_066_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	121	0	1	01	01	H5619_121_0	4	2	2	2		2			2	2		2							2	1		500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	145	0	1	01	01	H5619_145_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	152	0	1	01	01	H5619_152_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	169	0	1	01	01	H5619_169_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	180	0	1	01	01	H5619_180_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	181	0	1	01	01	H5619_181_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	183	0	1	01	01	H5619_183_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	185	0	1	01	01	H5619_185_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5652	009	0	1	02	01	H5652_009_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H5828	008	0	1	02	01	H5828_008_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	008	0	1	02	01	H5828_008_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	008	0	1	02	01	H5828_008_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	013	0	1	02	01	H5828_013_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	013	0	1	02	01	H5828_013_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	013	0	1	02	01	H5828_013_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	014	0	1	02	01	H5828_014_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	014	0	1	02	01	H5828_014_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	014	0	1	02	01	H5828_014_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	015	0	1	02	01	H5828_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	015	0	1	02	01	H5828_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	015	0	1	02	01	H5828_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	016	0	1	02	01	H5828_016_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	016	0	1	02	01	H5828_016_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	016	0	1	02	01	H5828_016_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	017	0	1	02	01	H5828_017_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	017	0	1	02	01	H5828_017_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	017	0	1	02	01	H5828_017_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	018	0	1	02	01	H5854_018_0	3	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	018	0	1	02	01	H5854_018_0	3	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	018	0	1	02	01	H5854_018_0	3	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	019	1	1	01	01	H5854_019_1	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	1	1	01	01	H5854_019_1	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	1	1	01	01	H5854_019_1	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	019	2	1	01	01	H5854_019_2	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	2	1	01	01	H5854_019_2	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	2	1	01	01	H5854_019_2	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5883	002	1	1	02	01	H5883_002_1	9								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	2	1	02	01	H5883_002_2	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	3	1	02	01	H5883_002_3	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	4	1	02	01	H5883_002_4	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	7	1	02	01	H5883_002_7	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	1	1	02	01	H5883_003_1	9								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	2	1	02	01	H5883_003_2	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	3	1	02	01	H5883_003_3	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	4	1	02	01	H5883_003_4	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	5	1	02	01	H5883_003_5	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	007	0	1	01	01	H5883_007_0	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	014	1	1	02	01	H5883_014_1	11								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	014	2	1	02	01	H5883_014_2	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	014	4	1	02	01	H5883_014_4	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	014	5	1	02	01	H5883_014_5	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	017	0	1	02	01	H5883_017_0	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5970	028	0	1	04	01	H5970_028_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6322	001	0	1	01	01	H6322_001_0	6								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				2	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	001	0	1	01	01	H6322_001_0	6								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				2	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				2	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				2	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	008	0	1	01	01	H6322_008_0	6								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				2	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	008	0	1	01	01	H6322_008_0	6								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				2	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6622	007	0	1	01	01	H6622_007_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	017	0	1	01	01	H6622_017_0	4	2	2	2		2			2	2		2							2	1		1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	028	0	1	01	01	H6622_028_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H6622	055	0	1	01	01	H6622_055_0	5	2	2	2		2			2	2		2							2	1		500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	075	0	1	01	01	H6622_075_0	6	2	2	2		2			2	2		2							2	2					2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															2						2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H6622	084	0	1	01	01	H6622_084_0	5	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	090	0	1	01	01	H6622_090_0	4	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	097	0	1	01	01	H6622_097_0	5	2	2	2		2			2	2		2							2	1		250.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	098	0	1	01	01	H6622_098_0	6	2	2	2		2			2			2							2	1		1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	1	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	1	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	1																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H6697	003	0	1	01	01	H6697_003_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H6706	001	0	1	02	01	H6706_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H6723	001	1	1	02	01	H6723_001_1	9	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	001	3	1	02	01	H6723_001_3	6	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	002	1	1	01	01	H6723_002_1	7																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	002	3	1	01	01	H6723_002_3	7																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	003	1	1	01	01	H6723_003_1	5	2			2				2	1	1	2					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																															001
H6723	003	3	1	01	01	H6723_003_3	5	2			2				2	2	2	2					2		2	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	007	0	1	02	01	H6988_007_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	007	0	1	02	01	H6988_007_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	007	0	1	02	01	H6988_007_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	009	0	1	02	01	H6988_009_0	6	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	009	0	1	02	01	H6988_009_0	6	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	009	0	1	02	01	H6988_009_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	010	0	1	02	01	H6988_010_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	010	0	1	02	01	H6988_010_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	010	0	1	02	01	H6988_010_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7063	001	0	1	04	01	H7063_001_0	5								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																															3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2	001
H7063	007	0	1	04	01	H7063_007_0	6								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																															3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	001	0	1	04	01	H7093_001_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7093	002	0	1	04	01	H7093_002_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	002	0	1	04	01	H7093_002_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	002	0	1	04	01	H7093_002_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	004	0	1	02	01	H7220_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	004	0	1	02	01	H7220_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	004	0	1	02	01	H7220_004_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	009	1	1	02	01	H7220_009_1	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	1	1	02	01	H7220_009_1	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	1	1	02	01	H7220_009_1	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	009	2	1	02	01	H7220_009_2	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	2	1	02	01	H7220_009_2	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	2	1	02	01	H7220_009_2	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	010	0	1	02	01	H7220_010_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	010	0	1	02	01	H7220_010_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	010	0	1	02	01	H7220_010_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7617	007	0	1	04	01	H7617_007_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	024	0	1	04	01	H7617_024_0	6	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	027	0	1	04	01	H7617_027_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	044	0	1	04	01	H7617_044_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	046	0	1	04	01	H7617_046_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	049	0	1	04	01	H7617_049_0	5	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	058	0	1	04	01	H7617_058_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	065	0	1	04	01	H7617_065_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	094	0	1	04	01	H7617_094_0	5	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	096	0	1	04	01	H7617_096_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	114	0	1	04	01	H7617_114_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	115	0	1	04	01	H7617_115_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	119	0	1	04	01	H7617_119_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	125	0	1	04	01	H7617_125_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	144	1	1	04	01	H7617_144_1	6	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	144	2	1	04	01	H7617_144_2	6	2	2	2		2			2	2		2							2	1	2	1000.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H8142	001	0	1	02	01	H8142_001_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	002	0	1	02	01	H8142_002_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	003	0	1	02	01	H8142_003_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	004	0	1	02	01	H8142_004_0	9																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months. Dentures are covered once every 5 years. Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime. Pulp capping is covered as needed. Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months. Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings. Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years. Denture adjustments once every 6 months. Dental rebases or relines once every 36 months. Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years. Denture adjustments once every 6 months. Dental rebases or relines once every 36 months. Tissue conditioning once every 36 months. Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions. Includes one brush biopsy every 24 months. Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months. General anesthesia and IV sedation, if medically/dentally necessary. Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	005	0	1	02	01	H8142_005_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months. General anesthesia and IV sedation, if medically/dentally necessary. Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	006	0	1	02	01	H8142_006_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	007	0	1	02	01	H8142_007_0	12																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8142	008	0	1	02	01	H8142_008_0	10																																																																																																																																		1	2		2000.00	3		2					2		3	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures are covered once every 5 years.  Crowns, inlays, onlays, bridges are covered once every 10 years.	3		50	75	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping is covered as needed.  Pulpal therapy, apexification, and calcification are covered once per tooth per lifetime.	1	75	75	75	2				2	2	3	2	1	6	Periodontal Surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		50	75	2				2	2																															3	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		50	75	2				2	2	3	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months.  Alveolplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Consultations once every 12 months.  General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2	001
H8145	052	0	1	09	04	H8145_052_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				2	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				2	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				2	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				2	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				2	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				2	2	001
H8211	005	0	1	04	01	H8211_005_0	2	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8211	006	0	1	04	01	H8211_006_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8211	011	0	1	04	01	H8211_011_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8385	005	0	1	04	01	H8385_005_0	11	1	1	1		1	1																																																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8385	006	0	1	04	01	H8385_006_0	11	1	1	1		1	1		1	1	1	1	1		1	1	1		1																																																				3	1				1	50	50	50	2				2	2																																																																																																																																																																																																																	001
H8432	009	0	1	02	01	H8432_009_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	009	0	1	02	01	H8432_009_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	009	0	1	02	01	H8432_009_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	010	0	1	01	01	H8432_010_0	6																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	010	0	1	01	01	H8432_010_0	6																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	010	0	1	01	01	H8432_010_0	6																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	011	0	1	01	01	H8432_011_0	6																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	011	0	1	01	01	H8432_011_0	6																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	011	0	1	01	01	H8432_011_0	6																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	040	0	1	02	01	H8432_040_0	5	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	040	0	1	02	01	H8432_040_0	5	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	040	0	1	02	01	H8432_040_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8604	014	1	1	04	01	H8604_014_1	7								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	014	2	1	04	01	H8604_014_2	7								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	015	0	1	04	01	H8604_015_0	7								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8764	001	0	1	01	01	H8764_001_0	7																																																																																																																																		1	2		2000.00	3		2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	003	0	1	01	01	H8764_003_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	003	0	1	01	01	H8764_003_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	004	0	1	01	01	H8764_004_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	004	0	1	01	01	H8764_004_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8768	005	0	1	04	01	H8768_005_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	007	0	1	04	01	H8768_007_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	008	0	1	04	01	H8768_008_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	009	0	1	04	01	H8768_009_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	010	0	1	04	01	H8768_010_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	011	0	1	04	01	H8768_011_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	013	0	1	04	01	H8768_013_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	016	0	1	04	01	H8768_016_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	017	1	1	04	01	H8768_017_1	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	017	2	1	04	01	H8768_017_2	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	022	0	1	04	01	H8768_022_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	023	0	1	04	01	H8768_023_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	024	0	1	04	01	H8768_024_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	027	0	1	04	01	H8768_027_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	034	0	1	04	01	H8768_034_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	040	0	1	04	01	H8768_040_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	046	0	1	04	01	H8768_046_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	055	1	1	04	01	H8768_055_1	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	055	2	1	04	01	H8768_055_2	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	058	0	1	04	01	H8768_058_0	5	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	059	0	1	04	01	H8768_059_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	061	0	1	04	01	H8768_061_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	063	0	1	04	01	H8768_063_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8768	064	0	1	04	01	H8768_064_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
H8832	001	0	1	04	01	H8832_001_0	9	2	2	2		2	2		2	2	2	2	2			2	2			1	2	1000.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2																															3	1				2				2				1	2	3	1				2				2				1	2																															001
H8832	002	0	1	04	01	H8832_002_0	9																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H8832	005	0	1	04	01	H8832_005_0	7																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H8849	001	0	1	02	01	H8849_001_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	001	0	1	02	01	H8849_001_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	001	0	1	02	01	H8849_001_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	005	0	1	02	01	H8849_005_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	005	0	1	02	01	H8849_005_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	005	0	1	02	01	H8849_005_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	006	0	1	02	01	H8849_006_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	006	0	1	02	01	H8849_006_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	006	0	1	02	01	H8849_006_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	009	0	1	02	01	H8849_009_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	009	0	1	02	01	H8849_009_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	009	0	1	02	01	H8849_009_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	032	0	1	02	01	H8849_032_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	032	0	1	02	01	H8849_032_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	032	0	1	02	01	H8849_032_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9003	001	0	1	02	01	H9003_001_0	7																			1		1500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9003	006	0	1	02	01	H9003_006_0	7																			1		1500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9003	008	0	1	02	01	H9003_008_0	9																			1		1500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	1		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				3		35	50	1	25.00	25.00	25.00	1	2	001
H9003	009	0	1	02	01	H9003_009_0	7																			1		1500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9065	002	0	1	02	01	H9065_002_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	002	0	1	02	01	H9065_002_0	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	002	0	1	02	01	H9065_002_0	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9065	008	0	1	01	01	H9065_008_0	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	008	0	1	01	01	H9065_008_0	4																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	008	0	1	01	01	H9065_008_0	4																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9065	014	0	1	02	01	H9065_014_0	5	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	014	0	1	02	01	H9065_014_0	5	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	014	0	1	02	01	H9065_014_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9065	015	0	1	02	01	H9065_015_0	3	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	015	0	1	02	01	H9065_015_0	3	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	015	0	1	02	01	H9065_015_0	3	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9179	001	0	1	01	01	H9179_001_0	8	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	001	0	1	01	01	H9179_001_0	8	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9179	003	0	1	01	01	H9179_003_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	003	0	1	01	01	H9179_003_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9179	004	0	1	01	01	H9179_004_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	004	0	1	01	01	H9179_004_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	006	0	1	02	01	H9525_006_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 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																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	006	0	1	02	01	H9525_006_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	006	0	1	02	01	H9525_006_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	1	1	02	01	H9525_013_1	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	1	1	02	01	H9525_013_1	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	1	1	02	01	H9525_013_1	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	5	1	02	01	H9525_013_5	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	5	1	02	01	H9525_013_5	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	5	1	02	01	H9525_013_5	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	021	1	1	02	01	H9525_021_1	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	021	1	1	02	01	H9525_021_1	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	021	1	1	02	01	H9525_021_1	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	021	2	1	02	01	H9525_021_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	021	2	1	02	01	H9525_021_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	021	2	1	02	01	H9525_021_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	021	3	1	02	01	H9525_021_3	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	021	3	1	02	01	H9525_021_3	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	021	3	1	02	01	H9525_021_3	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	021	4	1	02	01	H9525_021_4	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	021	4	1	02	01	H9525_021_4	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	021	4	1	02	01	H9525_021_4	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	021	5	1	02	01	H9525_021_5	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	021	5	1	02	01	H9525_021_5	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	021	5	1	02	01	H9525_021_5	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9572	001	1	1	04	01	H9572_001_1	10								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	2	1	04	01	H9572_001_2	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	3	1	04	01	H9572_001_3	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	4	1	04	01	H9572_001_4	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	6	1	04	01	H9572_001_6	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	1	1	04	01	H9572_002_1	12								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	2	1	04	01	H9572_002_2	11								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	3	1	04	01	H9572_002_3	11								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	4	1	04	01	H9572_002_4	11								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	6	1	04	01	H9572_002_6	11								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	003	1	1	04	01	H9572_003_1	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	2	1	04	01	H9572_003_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	3	1	04	01	H9572_003_3	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	4	1	04	01	H9572_003_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	6	1	04	01	H9572_003_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	004	1	1	04	01	H9572_004_1	11								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	2	1	04	01	H9572_004_2	10								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	4	1	04	01	H9572_004_4	10								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	6	1	04	01	H9572_004_6	10								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	1	1	04	01	H9572_007_1	12								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	2	1	04	01	H9572_007_2	12								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	008	0	1	04	01	H9572_008_0	9																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	Fillings, Crowns, Crown Repairs. Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2	3	2	1	6	Root Canals - once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Deep Cleaning - periodontal scaling and root planing.Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2	3	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	1	25	25	25	2				2	2																3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	009	0	1	04	01	H9572_009_0	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	010	0	1	04	01	H9572_010_0	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays-Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9808	010	0	1	04	01	H9808_010_0	10	2	2	2	2	2														2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	3	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				1	2																3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9827	003	0	1	01	01	H9827_003_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes, unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	003	0	1	01	01	H9827_003_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9834	001	0	1	01	01	H9834_001_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	003	0	1	01	01	H9834_003_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	004	0	1	01	01	H9834_004_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	006	0	1	01	01	H9834_006_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	007	0	1	01	01	H9834_007_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
R0110	005	0	1	31	11	R0110_005_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	008	0	1	31	11	R0110_008_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	012	0	1	31	11	R0110_012_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	020	0	1	31	11	R0110_020_0	4	2	2	2		2			2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R2604	005	0	1	31	11	R2604_005_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
R4182	003	0	1	31	11	R4182_003_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R4182	004	0	1	31	11	R4182_004_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5361	002	0	1	31	11	R5361_002_0	4	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5941	014	0	1	31	11	R5941_014_0	5	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	014	0	1	31	11	R5941_014_0	5	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	014	0	1	31	11	R5941_014_0	5	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5941	016	0	1	31	11	R5941_016_0	4	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	016	0	1	31	11	R5941_016_0	4	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	016	0	1	31	11	R5941_016_0	4	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R6694	006	0	1	31	11	R6694_006_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2	3	2	4	6	four visits other	1	50	50	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R6801	009	0	1	31	11	R6801_009_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
R6801	012	0	1	31	11	R6801_012_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				2	2	001
R7220	002	0	1	31	11	R7220_002_0	6	2	2	2		2			2			2							2	1	2	1500.00	3		2				2					2					2		3	2	5	6	comp oral eval/perio exam 1/3 yrs, emerg diag exam, periodic oral exam 2/yr	1	0	0	0	2				2	2	3	2	8	6	bitewing x-rays 1/yr, intraoral x-rays 6/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2																3	2	2	3		1	0	0	0	2				2	2																															1	1					2					2		3	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	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	6	6	perio maint 4/yr, scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	1	0	0	0	2				1	2	3	2	12	6	comp dentures, part dentures 1/5 yrs, denture adj, denture repair - base and 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																															3	2	4	6	bridge recement 1/yr, bridges-crown 2/5 yrs, bridges-pontic 1/5 yrs	1	50	50	50	2				1	2	3	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	3		0	50	2				1	2																3	2	6	6	emerg treatment for pain, necessary general anesthesia with covered service 2/yr, necessary incremental anesthesia with covered service  as needed with covered codes/yr, necessary nitrous oxide/analgesia with covered service 1 unit(s) per visit, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
