a Type Your Fees Directly into the Form and Use the Submit Buttons at the End to Submit Electronically

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1 DMO Usul nd Customry Fee Profile Type Your Fees Directly into the Form nd Use the Submit Buttons t the End to Submit Electroniclly Office Nme Address City, Stte, Zip Telephone # Office code (PBG) TIN ADA code* ADA description Usul fee D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0290 D0330 D0340 D0391 D0411 D0414 D0460 D0470 D0473 Periodic orl evlution Limited orl evlution problem focused Orl evlution for ptient under three yers of ge nd counseling with primry cregiver Comprehensive orl evlution- new or estblished ptient Detiled nd extensive orl evlution problem focused, by report Re-evlution limited, problem focused (estblished ptient; not post-opertive visit) Comprehensive periodontl evlution new or estblished ptient Complete series of rdiogrphic imges Introrl - peripicl first rdiogrphic imge Introrl - peripicl ech dditionl rdiogrphic imge Occlusl rdiogrphic imge Extr-orl-2D projection rdiogrphic imge creted using sttionry rdition source nd detector Extr-orl posterior dentl rdiogrphic imge Bitewing single rdiogrphic imge Bitewings two rdiogrphic imges Bitewings three rdiogrphic imges Bitewings four rdiogrphic imges Verticl bitewings 7 to 8 rdiogrphic imges Posterior-nterior or lterl skull nd fcil bone survey rdiogrphic imge Pnormic rdiogrphic imge 2D cephlometric rdiogrphic imge-cquisition, mesurement nd nlysis Interprettion of dignostic imge by prctitioner not ssocited with cpture of the imge, including report HbA1c in office point of service testing Lbortory processing of microbil specimen to include culture nd sensitivity studies, preprtion nd trnsmission of written report Pulp vitlity tests Dignostic csts Accession of tissue, gross nd microscopic exmintion, preprtion nd trnsmission of written report Pge 1 of 12

2 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D0474 Accession of tissue, gross nd microscopic exmintion, including ssessment of surgicl mrgins for presence of disese, preprtion nd trnsmission of written report D0502 Other orl pthology procedures, by report D0600 Non-ionizing dignostic procedure cpble of quntifying, monitoring nd recording chnges in structure of enmel, dentin nd cementum D1110 Prophylxis dult D1120 Prophylxis child D1206 Topicl ppliction of fluoride vrnish D1208 Topicl ppliction of fluoride excluding vrnish D1351 Preventive resin restortion in moderte to high cries risk ptient permnent tooth D1352 Selnt (per tooth) D1353 Selnt repir - per tooth D1354 Interim crries rresting medicment ppliction - per tooth D1510 Spce mintiner fixed - unilterl D1515 Spce mintiner fixed bilterl D1520 Spce mintiner removble unilterl D1525 Spce mintiner removble bilterl D1550 Recementtion of spce mintiner D1555 Removl of fixed spce mintiner performed by dentist or prctice tht did not originlly plce the pplince D1575 Distl shoe spce mintiner - fixed - unilterl D2140 Amlgm restortion, one surfce, primry or permnent D2150 Amlgm restortion, two surfces, primry or permnent D2160 Amlgm restortion, three surfces, primry or permnent D2161 Amlgm restortion, four or more surfces, primry or permnent D2330 Resin-bsed composite restortion, one surfce, nterior D2331 Resin-bsed composite restortion, two surfces, nterior D2332 Resin-bsed composite restortion, three or more surfces, nterior D2335 Resin-bsed composite restortion, four or more surfces or involving incisl ngle, nterior D2390 Resin-bsed composite crown, nterior D2391 Resin-bsed composite restortion, one surfce, posterior D2392 Resin-bsed composite restortion, two surfces, posterior D2393 Resin-bsed composite restortion, three surfces, posterior D2394 Resin-bsed composite restortion, four or more surfces, posterior D2410 Gold foil restortion one surfce D2420 Gold foil restortion two surfces D2430 Gold foil restortion three surfces D2510 Inly metllic one surfce D2520 Inly metllic two surfces D2530 Inly metllic three or more surfces Pge 2 of 12

3 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D2542 Only metllic two surfces D2543 Only metllic three surfces D2544 Only metllic four or more surfces D2610 Inly porcelin/cermic one surfce D2620 Inly porcelin/cermic two surfces D2630 Inly porcelin/cermic three or more surfces D2642 Only porcelin/cermic two surfces D2643 Only porcelin/cermic three surfces D2644 Only porcelin/cermic four or more surfces D2650 Inly resin-bsed composite one surfce D2651 Inly resin-bsed composite two surfces D2652 Inly resin-bsed composite three or more surfces D2662 Only resin-bsed composite two surfces D2663 Only resin-bsed composite three surfces D2664 Only resin-bsed composite four or more surfces D2710 Crown resin-bsed composite (indirect) D2712 Crown ¾ resin-bsed composite (indirect) D2720 Crown resin with high noble metl D2721 Crown resin with predominntly bse metl D2722 Crown resin with noble metl D2740 Crown porcelin/cermic D2750 Crown porcelin fused to high noble metl D2751 Crown porcelin fused to predominntly bse metl D2752 Crown porcelin fused to noble metl D2780 Crown ¾ cst high noble metl D2781 Crown ¾ cst predominntly bse metl D2782 Crown ¾ cst noble metl D2790 Crown full cst high noble metl D2791 Crown full cst predominntly bse metl D2792 Crown full cst noble metl D2794 Crown titnium D2799 Provisionl crown - further tretment or completion of dignosis necessry prior to finl impression D2910 Recement or re-bond inly, only, veneer or prtil coverge restortion D2915 Recement or re-bond indirectly fbricted or prefbricted post nd core D2920 Recement crown D2921 Rettchment of tooth frgment, incisl edge or cusp. D2929 Prefbricted porcelin/cermic crown - primry tooth D2930 Prefbricted stinless steel crown primry tooth D2931 Prefbricted stinless steel crown permnent tooth D2932 Prefbricted resin crown D2933 Prefbricted stinless steel crown w/resin window Pge 3 of 12

4 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D2940 Protective restortion D2941 Interim therpeutic restortion - primry dentititon D2950 Crown buildup, including ny pins D2951 Pin retention - per tooth D2952 Post nd core in ddition to crown, indirectly fbricted D2954 Prefbricted post nd core D2955 Post removl D2957 Ech dditionl prefbricted post sme tooth D2960 Lbil veneer (resin lminte) - chirside D2961 Lbil veneer (resin lminte) - lbortory D2962 Lbil veneer (porcelin lminte) - lbortory D2971 Additionl procedures to construct new crown under existing prtil denture frmework D2980 Crown repir necessitted by restortive mteril filure D2981 Inly repir necessitted by restortive mteril filure D2982 Only repir necessitted by restortive mteril filure D2983 Veneer repir necessitted by restortive mteril filure D2990 Resin infiltrtion of incipient smooth surfce lesions D3110 Pulp-cp direct D3120 Pulp-cp indirect D3220 Therpeutic pulpotomy D3221 Pulpl debridement, primry & permnent D3222 Prtil pulpotomy for pexogenesis - permnent tooth with incomplete root development D3230 Pulpl therpy nterior primry D3240 Pulpl therpy posterior primry D3310 Root cnl nterior D3320 Endodontic therpy, premolr tooth (excluding finl restortions) D3330 Endodontic therpy, molr tooth (excluding finl restortions) D3331 Tretment of root cnl obstruction, non-surgicl ccess D3332 Incomplete endodontic therpy; inoperble, unrestorble or frctured tooth D3333 Internl root repir of perfortion D3346 Retretment of root cnl - nterior D3347 Retretment of prevous root cnl - premolr D3348 Retretment of root cnl - molr D3351 Apexifiction / reclcifction initil visit (picl closure / clcific repir of perfortions, root resorption, pulp spce, disinfection, etc.) D3352 Apexifiction / reclcifiction Interim mediction replcement (picl closure / clcifiction repir of perfortions, root resorption, pulp spce disinfection, etc.) D3353 Apexifiction finl visit D3410 Apicoectomy nterior Pge 4 of 12

5 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D3421 Apicoectomy premolr (first root). Does not include plcement of retrogrde filling mteril. If more thn one root is treted, see D3426 D3425 Apicoectomy molr (first root) D3426 Apicoectomy (ech dditionl root). Typiclly used for premolr nd molr surgeries when more thn one root is treted in sme procedure. This does not include retrogrde filling mteril plcement. D3430 Retrogrde filling (per root) D3450 Root mputtion D3920 Hemisection D4210 Gingivectomy or gingivoplsty four or more contiguous teeth or tooth bounded spces per qudrnt D4211 Gingivectomy or gingivoplsty one to three contiguous teeth or tooth bounded spces per qudrnt D4212 D4230 Gingivectomy or gingivoplsty to llow ccess for restortive procedure, per tooth Antomicl crown exposure - four or more contiguous teeth or bounded tooth spces per qudrnt. This procedure is utilized in n otherwise periodontlly helthy re to remove enlrged gingivl tissue nd supporting bone (ostectomy) to provide ntomiclly corret gingivl reltionship. D4231 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4270 D4273 Antomicl crown exposure - one to three contiguous teeth or bounded tooth spces per qudrnt. This procedure is utilized in n otherwise periodontlly helthy re to remove enlrged gingivl tissue nd supporting bone (ostectomy) to provide ntomiclly corret gingivl reltionship. Gingivl flp, including root plnning four or more contiguous teeth or bounded teeth spces, per qudrnt Gingivl flp procedure, including root plning one to three contiguous teeth or bounded teeth spces per qudrnt Apiclly positioned flp Clinicl crown lengthening - hrd tissue Osseous surgery (including evlution of full thickness flp entry nd closure) four or more contiguous teeth or bounded teeth spces, per qudrn Osseous surgery (including evlution of full thickness flp entry nd closure) one to three contiguous teeth or bounded teeth spces, per qudrnt Bone replcement grft first site in qudrnt Bone replcement grft ech dditionl site in qudrnt Biologic mterils to id in soft nd osseous tissue regenertion Guided tissue regenertion resorbble brrier, per site Pedicle soft tissue grft procedure Autogenous connective tissue grft procedures(including donor nd recipient surgicl sites) first tooth, implnt or edentulous tooth position in grft Pge 5 of 12

6 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D4274 Distl or proximl wedge D4275 Non-utogenous connective tissue grft (including recipient site nd donor mteril) first tooth, implnt or edentulous tooth position in grft D4276 Combined connective tissue nd double pedicle grft, per tooth D4277 Free soft tissue grft procedure(including recipient nd donor surgicl sites) first Free soft tissue grft procedure(including recipient nd donor surgicl sites) ech D4278 dditionl contiguous tooth, implnt or edentulous tooth position in sme grft site D4283 Autogenous connective tissue grft procedure(including donor nd recipient Non-utogenous connective tissue grft procedure(including donor nd recipient D4285 surgicl sites)-ech dditionl contiguous tooth, implnt or edentulous tooth position in sme grft site D4341 Periodontl scling nd root plning four or more teeth per qudrnt D4342 Periodontl scling nd root plning one to three teeth, per qudrnt D4346 Scling in presence of generlized moderte or severe gingivl inflmmtion - full mouth, fter orl evlution Full mouth debridement to enble comprehensive orl evlution nd dignosis on subsequent visit. Full mouth debridement involves the preliminry removl D4355 of plque nd clculus tht interferes with the bility of the dentist to perform comprehensive orl evlution. Not to be completed on the sme dy s D0150, D0160, or D0180. D4381 Loclized delivery of ntimicrobil gents vi controlled relese vehicle into disesed creviculr tissue, per tooth D4910 Periodontl mintennce D5110 Complete denture mxillry D5120 Complete denture - mndibulr D5130 Immedite denture mxillry D5140 Immedite denture - mndibulr D5211 Mxillry prtil denture resin bse D5212 Mndibulr prtil denture resin bse D5213 Mxillry prtil denture cst metl frmework with resin denture bses D5214 Mndibulr prtil denture cst metl frmework with resin denture bses D5221 Immedite mxillry prtil denture - resin bse(including ny conventionl clsps, rests nd teeth) D5222 Immedite mndibulr prtil denture - resin bse(including ny conventionl clsps, rests nd teeth) Immedite mxillry prtil denture - cst metl frmework with resin denture D5223 bses (including ny conventionl clsps, rests nd teeth) Includes limited followup cre only; does not include future rebsing D5224 Immedite mndibulr prtil denture - cst metl frmework with resin denture bses (including ny conventionl clsps, rests nd teeth) D5225 Mxillry prtil denture flexible bse (including ny clsps, rests nd teeth) D5226 Mndibulr prtil denture flexible bse (including ny clsps, rests nd teeth) Pge 6 of 12

7 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D5281 Unilterl prtil denture D5410 Adjust complete denture - mxillry D5411 Adjust complete denture - mndibulr D5421 Adjust prtil denture - mxillry D5422 D5511 D5512 D5520 D5611 D5612 D5621 D5622 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5863 D5864 D5865 D5866 D6058 D6059 Adjust prtil denture - mndibulr Repir broken complete denture bse, mndibulr Repir broken complete denture bse, mxillry Replce broken or missing teeth Repir resin prtil denture bse, mndibulr Repir resin prtil denture bse, mxillry Repir cst prtil frmework, mndibulr Repir cst prtil frmework, mxillry Repir or replce broken clsp - per tooth Replce broken tooth per tooth Add tooth to existing prtil denture dd clsp to existing prtil denture - per tooth Replce ll teeth & crylic on cst metl frmework (mxillry) Replce ll teeth & crylic on cst metl frmework (mndibulr) Rebse complete mxillry denture Rebse complete mndibulr denture Rebse mxillry prtil denture Rebse mndibulr prtil denture Reline complete mxillry denture (chirside) Reline complete mndibulr denture (chirside) Reline mxillry prtil denture (chirside) Reline mndibulr prtil denture (chirside) Reline complete mxillry denture (lbortory) Reline complete mndibulr denture (lbortory) Reline mxillry prtil denture (lbortory) Reline mndibulr prtil denture (lbortory) Interim complete denture (mxillry) Interim complete denture (mndibulr) Interim prtil denture (mxillry) Interim prtil denture (mndibulr) Tissue conditioning, mxillry Tissue conditioning, mndibulr Overdenture - complete mxillry Overdenture - prtil mxillry Overdenture - complete mndibulr Overdenture - prtil mndibulr Abutment supported porcelin/cermic crown Abutment supported porcelin fused to metl crown (high noble metl) Pge 7 of 12

8 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D6060 Abutment supported porcelin fused to metl crown (predominntly bse metl) D6061 Abutment supported porcelin fused to metl crown (noble metl) D6062 Abutment supported cst metl crown (high noble metl) D6063 Abutment supported cst metl crown (predominntly bse metl) D6064 Abutment supported cst metl crown (noble metl) D6065 Implnt supported porcelin/cermic crown D6066 Implnt supported porcelin fused to metl crown (titnium, titnium lloy, high noble metl) D6067 Implnt supported metl crown (titnium, titnium lloy, high noble metl) D6068 Abutment supported retiner for porcelin/cermic FPD D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6081 D6085 D6096 D6110 D6111 D6112 D6113 D6114 D6115 D6116 Abutment supported retiner for porcelin fused to metl FPD (high noble metl) Abutment supported retiner for porcelin fused to metl FPD (predominntly bse metl) Abutment supported retiner for porcelin fused to metl FPD (noble metl) Abutment supported retiner cst metl FPD (high noble metl) Abutment supported retiner for cst metl FPD (predominntly bse metl) Abutment supported retiner cst metl FPD (noble metl) Implnt supported retiner for cermic FPD Implnt supported retiner for porcelin fused to metl FPD (titnium, titnium lloy, or high noble metl) Implnt supported retiner for cst metl FPD (titnium, titnium lloy, or high noble metl) Scling nd debridement in the presence of inflmmtion or mucositis of single implnt, including clening of the implnt surfces, without flp entry nd closure. Not to be performed in conjunction with D1110, D4910 or D4346. Provisionl implnt crown Remove broken implnt retining screw Implnt/butment supported removble denture for completely edentulous rchmxillry Implnt/butment supported removble denture for completely edentulous rchmndibulr Implnt/butment supported removble denture for prtilly edentulous rchmxillry Implnt/butment supported removble denture for prtilly edentulous rchmndibulr Implnt/butment supported fixed denture for completely edentulous rchmxillry Implnt/butment supported fixed denture for completely edentulous rchmndibulr Implnt/butment supported fixed denture for prtilly edentulous rchmxillry Pge 8 of 12

9 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D6117 Implnt/butment supported fixed denture for prtilly edentulous rchmndibulr D6118 Implnt/butment supported interim fixed denture for edentulous rch - mndibulr D6119 Implnt/butment supported interim fixed denture for edentulous rch - mxillry D6205 Pontic indirect resin bsed composite D6210 Pontic cst high noble metl D6211 Pontic cse bse metl D6212 Pontic cst noble metl D6214 Pontic titnium D6240 Pontic porcelin fused to high noble metl D6241 Pontic porcelin fused to predominntly bse metl D6242 Pontic porcelin fused to noble metl D6245 Pontic porcelin/cermic D6250 Pontic resin with high noble metl D6251 Pontic resin with predominntly bse metl D6252 Pontic resin with noble metl D6545 Retiner cst metl for resin bonded fixed prosthesis D6548 Retiner porcelin/cermic for resin bonded fixed prosthesis D6549 Resin retiner for resin bonded fixed prosthesis D6600 Inly porcelin/cermic, two surfces D6601 Inly porcelin/cermic, three or more surfces D6602 Inly cst high noble metl, two surfces D6603 Inly cst high noble metl, three or more surfces D6604 Inly cst predominntly bse metl, two surfces D6605 Inly cst predominntly bse metl, three or more surfces D6606 Inly cst noble metl, two surfces D6607 Retiner Inly cst noble metl, three or more surfces D6608 Retiner Only porcelin/cermic, two surfces D6609 Retiner Only porcelin/cermic, three or more surfces D6610 Retiner Only cst high noble metl, two surfces D6611 Retiner Only cst high noble metl, three or more surfces D6612 Retiner Only cst predominntly bse metl, two surfces D6613 Retiner Only cst predominntly bse metl, three or more surfces D6614 Retiner Only cst noble metl, two surfces D6615 Retiner Only cst noble metl, three or more surfces D6624 Retiner Inly titnium D6634 Retiner Only titnium D6710 Retiner Crown - indirect resin bsed composite D6720 Retiner Crown resin/high noble metl D6721 Retiner Crown resin/predominntly bse metl D6722 Retiner Crown resin/noble metl Pge 9 of 12

10 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D6740 Retiner Crown porcelin/cermic D6750 Retiner Crown porcelin/high noble metl D6751 Retiner Crown porcelin/ predominntly bse metl D6752 Retiner Crown porcelin/noble metl D6780 Retiner Crown ¾ high noble metl D6781 Retiner Crown ¾ cst predominntly bse metl D6782 Retiner Crown ¾ cst noble metl D6783 Retiner Crown ¾ porcelin/cermic D6790 Retiner Crown full cst high noble metl D6791 Retiner Crown full bse metl D6792 Retiner Crown full noble metl D6794 Retiner Crown titnium D6930 Recement or re-bond fixed prtil denture retiners D6940 Stress breker D6980 Fixed prtil denture repir necessitted by restortive mteril filure D7111 Extrction, coronl remnnts primry tooth. Removl of soft tissue retined coronl remnnts. D7140 Extrction, erupted teeth or exposed root (elevtion nd/or forceps removl) D7210 Surgicl removl of erupted tooth requiring removl of bone nd/or sectioning of tooth nd including elevtion of mucoperiostel flp if indicted D7220 Removl of impcted tooth soft tissue D7230 Removl of impcted tooth prtilly bony D7240 Removl of impcted tooth completely bony D7241 Removl of impcted tooth completely bony, with unusul surgicl complictions D7250 Surgicl removl of residul tooth roots D7251 Coronectomy intentionl prtil tooth removl D7260 Orontrl fistul closure D7261 Primry closure of sinus perfortion D7272 Tooth trnsplnttion (includes reimplnttion from one site to nother) D7280 Surgicl ccess of n unerupted tooth D7283 Plcement of device to fcilitte eruption of impcted tooth D7285 Incisionl biopsy of orl tissue hrd (bone, tooth) D7286 Incisionl biopsy of orl tissue soft D7287 Exfolitive cytologicl smple collection D7288 Brush biopsy trnsepithelil smple collection D7296 Corticotomy - one to three teeth or tooth spces, per qudrnt D7297 Corticotomy - four or more teeth or tooth spces, per qudrnt D7310 Alveoloplsty in conjunction with extrctions four or more teeth or tooth spces, per qudrnt D7311 Alveoloplsty in conjunction with extrctions one to three teeth or tooth spces, per qudrnt Pge 10 of 12

11 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D7320 Alveoloplsty not in conjunction with extrctions four or more teeth or tooth spces, per qudrnt D7321 Alveoloplsty not in conjunction with extrctions one to three teeth or tooth spces, per qudrnt D7450 Removl of benign odontogenic cyst or tumor lesion dimeter up to 1.25 cm D7451 Removl of benign odontogenic cyst or tumor lesion dimeter greter thn 1.25 cm D7471 Removl of lterl exostosis per site D7472 Removl of torus pltinus D7473 Removl of torus mndibulris D7485 Surgicl reduction of osseous tuberosity D7510 Incision & dringe of bscess introrl soft tissue D7511 Incision nd dringe of bscess introrl soft tissue complicted (includes dringe of multiple fscil spces) D7520 Incision & dringe of bscess extrorl soft tissue D7521 Incision nd dringe of bscess extrorl soft tissue complicted (includes dringe of multiple fscil spces) D7530 Remove foreign body from mucos, skin or subcutneous lveolr tissue D7540 Removl of rection-producing foreign body D7550 Prtil ostectomy/sequestrectomy for removl of non-vitl bone D7953 Bone replcement grft for ridge preservtion per site D7960 Frenulectomy lso known s frenectomy or frenotomy - seprte procedure not incidentl to nother procedure D7963 Frenuloplsty D7970 Excision of hyperplstic tissue per rch D7971 Excision of pericoronl gingiv D7979 Non-surgicl silolithotomy D7980 Surgicl silolithotomy. Procedure by which stone within slivry glnd or its duct is removed, either introrlly or extrorlly. D7983 Closure of slivry fistul D8210 Removble pplince therpy D8220 Fixed pplince therpy D8695 Removl of fixed orthodontic pplinces for resons other thn completion of tretment D9110 Pllitive (emergency) tretment of dentl pin minor procedures D9120 Fixed prtil denture sectioning D9222 Deep sedtion/generl nesthesi - first 15 minute increment D9223 Deep sedtion/generl nesthesi - ech subsequent 15 minute increment D9239 Intrvenous moderte(conscious) sedtion/nlgesi - first 15 minutes D9243 Intrvenous moderte(conscious) sedtion/nlgesi ech subsequent 15 minute increment D9310 Consulttion (dignostic service provided by dentist or physicin other thn requesting dentist or physicin) D9430 Office visit for observtion no other services performed Pge 11 of 12

12 Usul nd Customry Fee Profile ADA code* ADA description Usul fee D9932 Clening nd inspection of removble complete denture, mxillry D9933 Clening nd inspection of removble complete denture, mndibulr D9934 Clening nd inspection of removble prtil denture, mxillry D9935 Clening nd inspection of removble prtil denture, mndibulr D9940 Occlusl gurd D9942 Repir nd/or reline of occlusl gurd D9943 Occlusl gurd djustment D9951 Occlusl djustment - limited D9952 Occlusl djustment - complete D9995 Teledentistry - synchronous; rel-time encounter D9996 Teledentistry - synchronous; informtion stored nd forwrded to dentist for subsequent review ---- Other dentl procedures uthorized by Compny ** Instructions: Plese forwrd this completed form to the Aetn Dentl Network Support office shown below, AK, AZ, CA, CO, HI, ID, IL, IN, IA, KS, MI, MN, MO, NE, NV, NM, ND, OK, OR, SD, TX, UT, WA, WI, nd WY Fx: e-mil: DentlNetworkSupportWoodlndHills@etn.com USPS mil: Aetn Dentl Burbnk Blvd. Suite 620 Woodlnd Hills, CA AL, AR, CT, DC, DE, FL, GA, KY, MA, MD, ME, MC, NC, NH, NJ, NY, OH, PA, RI, SC, TN, VA, nd WV Fx: e-mil: DentlPDSEst@etn.com USPS mil: Aetn Dentl Est 9000 Southside Blvd. Bldg. 100 Jcksonville, FL Dentl Office Guide (3/11) - Pge III-3 - Usul nd Customry Fee Profile (UCF) "...Only the Aetn pproved fee profile my be used to clculte ptient copyments on percentge copyment plns or for noncovered services. If you implement new UCF profile, (limited to once per yer) it must be submitted to Aetn for review nd pprovl. When the updted UCF profile is pproved, you cn use the new profile for determining ptient copyments. If you do not provide n updted UCF, the pplicble member copyments will be clculted systemticlly, bsed on the current fee on file for your office or the verge chrge for your zip code re if there is no pproved UCF on file." Aetn is the brnd nme used for products nd services provided by one or more of the Aetn group of subsidiry compnies. DMO plns re underwritten by Aetn Dentl Inc., Aetn Dentl of Cliforni Inc., Aetn Helth Inc. nd/or Aetn Life Insurnce Compny, nd in Texs by Aetn Dentl Inc., nd in Arizon by Aetn Helth Inc. (Aetn). Ech insurer hs sole finncil responsibility for its own products. Pge 12 of 12