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EXHIBIT I <br /> <br /> TABLE OF ALLOWANCES FOR ORTHODONTICS <br /> (To be used for cases submitted by non-participating* dentists) <br /> of the amounts listed in this table of allowances will be paid toward the charges of the dentist providing <br /> services in accordance with the terms and conditions of the applicable group dental care contract. Such <br /> be paid periodically when dentist has completed services and upon proper presentation of statement for <br /> rendered. <br /> PROCEDURES <br /> <br /> 129 Orthodontic Survey including entire denture series <br /> and all other films including cephalometrics and photos $ 25.00 <br /> 125 Panagraphic Film 12.00 <br /> <br /> Extraoral Head Film <br /> 126 One Film 8.00 <br /> 127 Each Additional 4.00 <br /> <br /> Orthodontic Traatment <br /> Permanent Dentition <br /> 850 Class I 700.00 <br /> 855 Class I I 700.00 <br /> 860 Class I II 700.00 <br /> Der~tition <br /> 870 Class I 400.00 <br /> 871 Class II 400.00 <br /> 872 Class II I 400.00 <br /> Primary Dentition <br /> 875 Class I 200.00 <br /> 876 Class II 200.00 <br /> 877 Class III 200.00 <br /> <br /> Appliances for Tooth Guidance <br /> 840 Removable 40.00 <br /> 843 Fixed or cemented 50.00 <br /> <br /> Appliances to Control Harmful Habits <br /> <br /> 845 Removabte 40.00 <br /> 847 Fixed or cemented 50.00 <br /> <br />*Non-participating Dentist - Dentist who does not agree to abide by the conditions governing dentist participation in <br /> Dental Service group dental care program. <br /> <br /> <br />