EXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE

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1 D0120 Periodic Exam D0140 Limited Oral Evaluation Problem Focused D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver D0150 Comprehensive Oral Exam New or Established Patient D0170 Re-Evaluation - Limited, Problem Focused - Established Patient; Not Post-Operative Visit) D0180 Comprehensive Periodontal Evaluation New or Established Patient D0210 Intraoral-Complete Series D0220 Intraoral-Periapical - First Film D0230 Intraoral-Periapical - Each Additional Film D0240 Intraoral-Occlusal View, Maxillary or Mandibular, Each D0270 Bitewings, One Film D0272 Bitewings, Two Films D0273 Bitewings, Three Films D0274 Bitewings, Four Films D0277 Vertical Bitewings 7-8 Films D0330 Panoramic Film D0415 Collection Of Microorganisms For Culture And Sensitivity D1110 Prophylaxis Adult D1120 Prophylaxis - Children D1201 Topical Application of Fluoride Including Prophylaxis - Children D1203 Topical Application of Fluoride Excluding Prophylaxis - Children D1205 Topical Application of Fluoride Including Prophylaxis - Adult D1351 Sealant 1st and 2nd Molars D1510 Space Maintainer - Fixed-Unilateral Band Type D1515 Space Maintainer Fixed-Lingual or Palatal Bar Type D1550 Recementation Space Maintainer D1555 Removal of Fixed Space Maintainer D2140 Amalgam Restoration - One Surface Primary D2140 Amalgam - One Surface Permanent D2150 Amalgam Restoration - Two Surfaces Primary D2150 Amalgam Restoration - Two Surfaces Permanent D2160 Amalgam Restoration - Three Surfaces Primary D2160 Amalgam Restoration - Three Surfaces Permanent D2161 Amalgam Restoration - Four or More Surfaces Primary D2161 Amalgam Restoration - Four or More Surfaces Permanent D2330 Anterior Resin Restoration - One Surface D2331 Anterior Resin Restoration - Two Surfaces D2332 Anterior Resin Restoration - Three Surfaces D2335 Anterior Resin Restoration - Four or More Surfaces or Incisal Angle D2391* Resin-Based Composite - One Surface, Posterior - Primary D2391* Resin-Based Composite - One Surface, Posterior - Permanent D2392* Resin-Based Composite - Two Surfaces, Posterior - Primary D2392* Resin-Based Composite - Two Surfaces, Posterior - Permanent D2393* Resin-Based Composite - Three Surfaces, Posterior - Primary D2393* Resin-Based Composite - Three Surfaces, Posterior - Permanent D2394* Resin-Based Composite Four or More Surfaces, Posterior - Primary D2394* Resin-Based Composite Four or More Surfaces, Posterior - Permanent D2510 Inlay - Metallic - One Surface D2520 Inlay - Metallic - Two Surfaces D2530 Inlay - Metallic - Three or More Surfaces D2542 Onlay - Metallic Two Surfaces D2543 Onlay Metallic Three Surfaces D2544 Onlay Metallic Four or More Surfaces D2610 Inlay Porcelain/Ceramic One Surface D2620 Inlay Porcelain/Ceramic Two Surfaces D2630 Inlay Porcelain/Ceramic Three or More Surfaces D2642 Onlay Porcelain/Ceramic Two Surfaces D2643 Onlay Porcelain/Ceramic Three Surfaces D2644 Onlay Porcelain/Ceramic Four or More Surfaces D2740 Porcelain Crown (Perm Processed) D2750 Porcelain/High Noble Metal Crown D2751 Porcelain/Predominantely Base Metal Crown D2752 Porcelain/Noble Metal Crown * Posterior composites may be downgraded to the corresponding amalgam fee. Please refer to the member s benefit schedule. Page 1

2 D2780 ¾ Cast High Noble Metal D2781 ¾ Cast Predominantly Base Metal D2782 ¾ Cast Noble Metal D2783 ¾ Porcelain/Ceramic D2790 Full Cast/High Noble Metal Crown D2791 Full Cast Predominantly Base Metal Crown D2792 Full Cast Noble Metal Crown D2910 Inlay ( Recementation) D2920 Crown ( Recementation ) D2930 Stainless Steel Crown ( Primary ) Prefabricated D2931 Stainless Steel Crown ( Permanent ) Prefabricated D2932 Resin Crown Prefabricated D2933 Stainless Steel Crown With Resin Window Prefabricated D2940 Sedative Fillings D2951 Pin Retention Per Tooth, When Necessary and Final Restore is Amalgam, Plastic or Resin. Fee Should be for Pin Retention Only. Restoration Should be Listed Separately D2952 Post and Core in Addition to Crown, Indirectly Fabricated Post and Core are Custom Fabricated as a Single Unit D2954 Prefabricated Post and Core in Addition to Crown D2960 Labial Veneer (Laminate) - Chair Side D2961 Labial Veneer (Resin Laminate) - Laboratory D2962 Labial Veneer (Porcelain Laminate) - Laboratory D2980 Crown Repair - by Report D3110 Direct Pulp Capping D3120 Indirect Pulp Capping ( Recalcification ) Including Temporary Restoration D3220 Therapeutic Pulpotomy ( in Addition to Restoration ) Per Treatment D3221 Pulpal Debridement - Primary and Permanent Teeth D3310 Root Canal Anterior D3320 Root Canal Bicuspid D3330 Root Canal Molar ( Three Canals ) D3340 Root Canal Molar ( Four Canals ) D3346 Re-Treatment of Previous Root Canal Anterior D3347 Re-Treatment of Previous Root Canal Bicuspid D3348 Re-Treatment of Previous Root Canal Molar ( Three Canals ) D3351 Apexification/Recalcification, Initial Visit D3352 Apexification/Recalcification, Interim Visits D3353 Apexification/Recalcification, Final Visit D3410 Apicoectomy/Anterior ( Separate Procedure ) D3421 Apicoectomy/Periradicular Surgery Bicuspid ( First Root ) D3425 Apicoectomy/Periradicular Surgery - Molar ( First Root ) D3426 Apicoectomy/Periradicular Surgery - Each Additional Root D3430 Retrograde Fill Per Root D3450 Root Amputation - Per Root D3920 Hemisection, Root Amputation D4210 Gingivectomy, Gingivolplasty of Soft Tissue Graft, Per Quadrant (Including Post-op Visits) D4211 Gingivectomy, Gingivolplasty or Soft Tissue Graft, Single Tooth D4240 Gingival Flap including Root Planing - Per Quadrant D4241 Gingival Flap Procedure 1-3 Teeth D4249 Crown Lengthening Hard Tissue D4260 Osseous Surgery, Four or More Contiguous Teeth Per Quadrant D4261 Osseous Surgery, One to Three Teeth Per Quadrant D4267 Guided tissue regeneration - non resorbable barrier, per site D4268 Guide Tissue Regen Inc Surg and Reentry D4270 Pedicle Soft Tissue Graft D4271 Free Soft Tissue Graft Procedure (including donor site surgery) D4273 Subepithelial Tissue Graft Procedure with Donor D4341 Periodontal Root Planing, Per Quadrant D4342 Periodontal Scaling One to Three Teeth, Per Quadrant D4355 Full Mouth Debridement D4910 Periodontal Recall ( Periodontal Prophylaxis ) Following Active Periodontal Therapy Maintenance Procedures after Active Therapy After Three Month ( Includes Any Examination Evaluation, Curettage, Root Planning and/or Polishing As May Be Necessary ) D5110 Complete Upper Denture D5120 Complete Lower Denture Page 2

3 D5130 Immediate Denture - Upper D5140 Immediate Denture - Lower D5211 Upper Part Resin Base w/conv. Clasps, Rests/Teeth D5212 Lower Part Resin Base w/conv. Clasps, Rests/Teeth D5213 Upper Partial Cast Mtl Resin Base w/conv. Clasps D5214 Lower Partial Cast Mtl Resin Base w/conv. Clasps D5225 Upper Partial Denture Flexible Base D5226 Lower Partial Denture Flexible Base D5281 Removable Unilateral Partial Denture One Piece Case Metal D5410 Denture Adjustment Complete - Upper D5411 Denture Adjustment Complete - Lower D5421 Denture Adjustment - Upper Partial D5422 Denture Adjustment - Lower Partial D5510 Repair Broken Complete Denture Base D5520 Replace One Broken Tooth Only Full Denture D5610 Repair Resin Denture Base D5620 Repair Cast Framework D5630 Repair or Replace Broken Clasp D5640 Replace One Broken Tooth - Partial D5650 Add First Tooth to a Denture ( New Extraction ) D5660 Add/Replace Clasp Metal Partial ( Dor 703 ) D5710 Rebase Complete Maxillary Denture D5711 Rebase Complete Mandibular Denture D5720 Rebase Upper Partial Denture D5721 Rebase Lower Partial Denture D5730 Office Reline ( Cold Core ) Acrylic FUD D5731 Office Reline ( Cold Core ) Acrylic FLD D5740 Office Reline ( Cold Core ) Acrylic PUD D5741 Office Reline ( Cold Core ) Acrylic PLD D5750 Denture Reline ( Laboratory ) FUD D5751 Denture Reline ( Laboratory ) FLD D5760 Denture Reline ( Laboratory ) PUD D5761 Denture Reline ( Laboratory ) PLD D5820 Interim Partial Denture - Upper ( Stayplate ) D5821 Interim Partial Denture - Lower ( Stayplate ) D5850 Tissue Conditioning Per Denture Upper D5851 Tissue Conditioning Per Denture - Lower D6010 Surgical Placement of Implant Body: Endosteal Implant D6040 Surgical Placement: Eposteal Implant D6050 Surgical Placement: Transosteal Implant D6055 Dental Implant Supported Connecting Bar D6066 Implant Supported Porcelain Fused to Metal Crown (Titanium, Titanium Alloy, High Noble Metal) D6080 Implant Maintenance Procedures, Including Removal of Prosthesis, Cleansing of Prosthesis and Abutments and Reinsertion of Prosthesis D6092 Recement Implant/Abutment Supported Crown D6093 Recement Implant/Abutment Supported Fixed Partial Denture D6210 Pontic Cast High Noble Metal D6211 Pontic Cast Predominantly Base Metal D6212 Pontic Cast Noble Metal D6240 Pontic - Porcelain High Noble Metal D6241 Pontic - Porcelain Predominantly Base Metal D6242 Pontic - Porcelain Noble Metal D6545 Retainer Cast Metal for Resin Bonded Fixed Prosthesis D6750 Abutment Crown Porcelain High Noble D6751 Abutment Crown Porcelain Predom Base Metal D6752 Abutment Crown Porcelain Noble Metal D6780 Abutment Crown - ¾ Cast High Noble D6790 Abutment Crown - Full Cast High Noble Metal D6791 Abutment Crown - Full Cast Predominantly Base Metal D6792 Abutment Crown - Full Cast Noble Metal D6930 Bridge ( Recementation ) D6970 Post And Core in Addition to Fixed Partial Denture Retainer, Indirectly Fabricated D6972 Prefab Post and Core in Add to Bridge Retainer D6980 Bridge Repair by Report Page 3

4 D7111 Coronal Remnants - Deciduous Tooth D7140 Extraction, Erupted Tooth or Exposed Root D7210 Surgical Removal of an Erupted Tooth D7220 Removal of Impacted Tooth ( Soft Tissue ) D7230 Removal of Impacted Tooth ( Partially Bony ) D7240 Removal of Impacted Tooth ( Complete Bony ) D7241 Removal of Impacted Tooth ( Complete Bony ) Unusual Surgical Complications D7250 Removal of Residual Root Totally Covered by Bone D7260 Closure of Oral Fistula of Maxillary Sinus D7270 Reimplantation and/or Stabilization of Accidentally Evulsed/Displaced Teeth and/or Alveous D7280 Crown Exposure with Attachment Placed for Orthodontic Traction D7282 Mobilization of Erupted or Malpositioned Tooth to Aid Eruption D7285 Biopsy of Oral Tissue Hard D7286 Biopsy of Oral Tissue, Incisional, Soft D7310 Alveoloplasty ( in Addition to Removal of Teeth ) Per Quadrant D7320 Alveoloplasty No Extraction - Per Quadrant D7340 Aveolopasty With Ridge Extension ( Secondary Eptheliazatioan ) D7410 Excision of Benign Lesion up to 1.25 cm D7411 Excision of Benign Lesion greater than 1.25 cm D7440 Excision of Malignant Tumor - Lesion Diameter up to 1.25 cm D7441 Excision of Malignant Tumor - Lesion Diameter greater than 1.25 cm D7450 Excision of Cyst, to 1.25cm D7451 Excision of Cyst, Larger than 1.25cm D7460 Removal Nonodontogenic Cyst/Tum up to 1.25cm D7461 Removal Nonodontogenic Cyst/Tum Greater Than 1.25cm D7471 Removal of Exostosis Maxilla or Mandible D7472 Removal of Torus Palatinus D7473 Removal of Torus Madibularis D7510 Intraoral Incision and Drainage of Abscess ( Soft Tissue ) D7520 Extraoral Incision and Drainage of Abscess D7530 Incision and Removal Foreign Body from Soft Tissue D7540 Removal of Foreign Body from Bone ( Independent Procedure ) D7550 Sequestrectomy for Osteomylities or Abscess, Superficial D7560 Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body D7910 Suture of Recent Small Wounds up to 5cm D7911 Complicated Suture up to 5cm D7912 Complicated Suture Greater Than 5cm D7960 Frenulectomy D7970 Excision of Hyperplastic Tissue, Per Arch D7971 Excision of Pericoronal Gingiva D7980 Sialolithotomy: Removal of Salivary Calculus, Intraorally D7981 Sialolithotomy: Removal of Salivary Calculus, Extraorally D7982 Dilation of Salivary Duct D7983 Closure of Salivary Fistula D8210 Appliance to Control Harmful Habits - Removable D8220 Appliance to Control Harmful Habits - Fixed D9110 Palliative ( Emergency ) Treatment of Dental Pain D9220 Anesthesia, General, One Half Hour D9221 Anesthesia, General, Each Additional 15 Minutes D9230 Nitrous Oxide D9241 Intravenous Conscious Sedation/Analgesia First 30 Minutes D9242 Intravenous Conscious Sedation/Analgesia Each Additional 15 Minutes D9310 Special Consultation (Specialist Only Separate Fee Only if Patient Not Treated by Consultant) D9430 Office Visit For Observation (during regularly scheduled hous) - No Other Services Performed D9440 Office Visit - After Regularly Scheduled Hours D9610 Therapeutic Parenteral Drug, Single Administration D9942 Repair and/or Reline of Occulusal Guard Orthodontist dentists will be reimbursed at 100% of the below fees as payment in full. 340 Cephalometric Film Ortho x-ray Survey Limited orthodontic treatment of primary dentition Limited orthodontic treatment of transitional dentition Limited orthodontic treatment of adult dentition Interceptive orthodontic treatment of the primary dentition Page 4

5 8060 Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the transitional dentition Ortho Comprehensive 24 Months Comprehensive orthodontic treatment of the adult dentition Appliance to Control Harmful Habbits Appliance to Control Harmful Habbits Pre-orthodontic treatment Periodic orthodontic treatment visit (as part of contract) Orthodontic retention Page 5

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