Please note a few important reminders to help expedite the process of dental claims/estimates:

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1 To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The member will be responsible for any balance due beyond what pays. does not contract with a network of dentists, so members may select a dentist of their choice. Please note a few important reminders to help expedite the process of dental claims/estimates: s Electronic Payer ID # is 38238, Group #: R40. Required documentation, including x-ray images, must be submitted on paper o Periodontal work full-mouth x-rays and charting o Soft tissue grafts - a narrative statement and charting o Bony impactions - a panorex x-ray o Completed endodontic work post-op periapical x-rays o Prosthetics a pre-op periapical x-ray, narrative statement for recommended crown; and x-ray of completed crown o Adult orthodontic treatment - x-rays and issue being corrected All wisdom teeth claims/estimates need to be submitted to dental first (Codes: D7230, D7240, D7241). Once the claim is paid through the dental plan, we will forward the balance to CIGNA who pays as secondary. If you have any questions, please call to speak with Amie at extension 233 or Ann at extension 229.

2 DIAGNOSTIC EXAMINATIONS FILLINGS (cont.) 0120 periodic exam two surfaces initial exam three surfaces emergency exam four surfaces or more oral evaluation under 3 yrs. of age 80 Composite Resin permanent or primary 0160 problem focused one surface palliative treatment two surfaces consultation (per session) three surfaces consultation with medical health care professional four surfaces and incisors 249 X-RAYS AND LAB 2390 resin based composite crown full mouth X-rays one surface intraoral X-ray first two surfaces intraoral X-ray each additional three surfaces occlusal X-rays four surfaces bitewing reattachment of tooth fragment bitewing stainless steel crown-primary tooth only bitewing stainless steel crown-permanent tooth only bitewing protective restoration/sedative filling vertical bitewing pin retention (per tooth) panorex X-ray 133 PERIODONTICS 0364 cone beam CT(< than 1 whole jaw) - by report periodontal consultations cone beam CT(1 full lower arch ) -by report gingivectomy per quadrant (4 or more teeth) cone beam CT(1 full upper arch) - by report gingivectomy (2 to 3 teeth) cone beam CT (view of both jaws) - by report gingivectomy (1 tooth) 175 PREVENTIVE 4220 subgingival curettage-per quadrant 175 CLEANING AND FLOURIDE TREATMENTS 4230 crown exposure-per quadrant cleaning-age 13 to adult crown exposure (1-3 teeth) cleaning-child through age gingival flap per quadrant (4 or more teeth) topical fluoride varnish-through age gingival flap (1 tooth) fluoride-child through age gingival flap (2 to 3 teeth) sealants-child through age crown lengthening resin-sealant/permanent tooth-through age osseous surgery-per quadrant sealant repair (per tooth/permanent) osseous surgery (1 tooth) 296 SPACE MAINTAINERS (up to age 14) 4262 osseous surgery (2 to 3 teeth) fixed unilateral bone graft-first site fixed-bilateral-maxillary bone graft-each additional site fixed-bilateral-mandibular biologic materials/tissue regeneration removable unilateral tissue regeneration/resorbable removable bilateral-maxillary tissue regeneration/nonresorbable removable bilateral-mandibular pedicle soft tissue graft-per report recementation (once per year) connective tissue graft- per report 1, distal shoe space maintainer - fixed unilateral mesial/distall wedge procedure single tooth 554 GUARDS (one type of guard once every 5 years) 4275 non-autogenous connective tissue graft athletic guard combined connective tissue graft occlusal guard-hard appliance-full arch free soft tissue graft-per report occlusal guard-soft appliance-full arch free soft tissue graft (larger) per report occlusal guard-hard appliance-partial arch periodontal scaling/root planing-per quadrant occlusal guard adjustment periodontal scaling /root planing (1 tooth) 71 BASIC CARE 4343 periodontal scaling /root planing (2 to 3 teeth) 106 FILLINGS 4346 scaling/gingival inflammation/full mouth 103 Amalgam permanent or primary 4355 difficult prophylaxis/scaling one surface periodontal maintenance procedure 103 Revised December 2018 Page 1 of 4

3 ENDODONTICS ORAL SURGERY (cont.) 3110 pulp capping/remineralization sinus augmentation by report 3220 vital pulpotomy sinus augmentation vertical approach by report 3221 pulpal debridement (primary & permanent) bone replacement graft for implants pulpal therapy-anterior primary tooth frenectomy pulpal therapy-posterior primary tooth frenuloplasty 254 Root Canal Therapy 7970 excision of hyperplastic tissue one root excision of pericoronal gingiva two roots non-surgical sialo lithotomy by report 3330 three roots 1, surgical sialo lithotomy by report four roots apexification/recalcification 1, apexification per visit apexification final visit /9223 /9243 general anesthesia - total benefit of all increments IV sedation - total benefit of all increments pulpal regeneration completion of treatment 100 MAJOR CARE Apicoectomy CROWNS AND BRIDGES 3410 anterior metallic inlay-1 surface bicuspid metallic inlay-2 surfaces molar metallic inlay-3 or more surfaces each additional root metallic onlay-3 surfaces retrograde filling-per root metallic onlay-4 or more surfaces root resection porcelain/ceramic inlay-1 surface hemi section porcelain/ceramic inlay-2 surfaces 406 EXTRACTIONS 2630 porcelain/ceramic inlay-3 or more surfaces coronal remnants-primary tooth porcelain/ceramic onlay-2 surfaces single tooth porcelain/ceramic onlay-3 surfaces root removal-exposed root porcelain/ceramic onlay-4 or more surfaces 605 SURGICAL EXTRACTIONS 2650 inlay-composite/resin-1 surface erupted tooth inlay-composite/resin-2 surfaces soft tissue impaction inlay-composite/resin-3 or more surfaces partial bony impaction onlay-composite/resin-2 surfaces complete bony impaction onlay-composite/resin-3 surfaces complete bony impaction-difficult onlay-composite/resin-4 or more surfaces residual root recovery plastic crown (laboratory) 203 ORAL SURGERY 2740 porcelain crown oroantral fistula closure by report 2750 porcelain to high noble metal surgical exposure of ortho porcelain with nonprecious metal surgical exposure of unerupted tooth porcelain with semiprecious metal device to facilitate eruption of impacted tooth three-quarter high noble metal biopsy oral tissue-hard three-quarter predominantly base metal biopsy oral tissue-soft three-quarter cast noble metal brush biopsy three-quarter crown/porcelain autogenous grafting/harvest of bone gold crown - full cast corticotomy-1 to 3 tooth spaces, per quadrant by report 2791 nonprecious crown corticotomy-4 or more tooth spaces, per quadrant by report 2792 semiprecious crown alveoplasty (per quadrant w/extractions) titanium crown alveoplasty (per quadrant w/no extractions) three-quarter cast crown-metallic vestibuloplasty (per arch, uncomplicated) recement or re-bond inlay or onlay vestibuloplasty (per arch, w/ridge extension) recement or re-bond crown cystectomy prefabricated resin crown removal of exostosis crown build-up pin retained incision and drainage abscess-intraoral cast post and core, in addition to crown incision and drainage abscess-extraoral prefabricated post and core osseous or cartilage graft by report 2955 post removal 53 Revised December 2018 Page 2 of 4

4 MAJOR CARE (cont.) MAJOR CARE (cont.) CROWNS AND BRIDGES (cont.) DENTURES (cont.) 2980 crown repair 130 Adjustments 2981 inlay repair complete upper denture onlay repair complete lower denture high noble metal pontic upper partial cast predominantly base pontic lower partial cast noble metal pontic 600 Repairs 6214 titanium pontic repair complete denture base, mandibular porcelain fused to high noble pontic repair complete denture base, maxillary porcelain to predominantly base pontic replace tooth porcelain to noble metal pontic repair resin partial denture base, mandibular porcelain to ceramic pontic repair resin partial denture base, maxillary cast metal retainer repair cast partial framework, mandibular porcelain to ceramic retainer repair cast partial framework, maxillary resin retainer repair or replace broken clasps (per tooth) porcelain to ceramic abutment broken tooth on partial (no other repairs) porcelain to gold abutment add tooth to partial porcelain to nonprecious abutment add clasp to existing partial (per tooth) porcelain to semiprecious abutment 591 Rebase 6790 high noble full cast abutment complete upper denture predominantly base full cast abutment complete lower denture noble metal full cast abutment upper partial denture titanium abutment lower partial denture recement bridge 91 Office Reline 6980 bridge repair complete upper denture 193 IMPLANT CROWNS 5731 complete lower denture abutment supported porcelain/ceramic upper partial denture abutment supported porcelain/high noble lower partial denture abutment supported porcelain/base metal 535 Laboratory Reline 6061 abutment supported porcelain/noble metal complete upper denture abutment supported high noble metal complete lower denture abutment supported cast metal upper partial denture abutment supported noble metal lower partial denture abutment supported titanium 580 Prosthetic Miscellaneous 6065 implant supported porcelain/ceramic tissue conditioning, maxillary implant supported porcelain/high noble metal tissue conditioning, mandibular implant supported high noble metal add metal substructure to acrylic full denture recement implant crown adjust prosthetic appliance 116 DENTURES 5993 maintenance & cleaning of prosthesis complete upper/maxillary complete lower/mandibular immediate upper/maxillary immediate lower/mandibular upper partial-acrylic base (includes clasps) lower partial-acrylic base (includes clasps) upper partial-cast metal framework lower partial-cast metal framework immediate upper/maxillary partial-resin base immediate lower/mandibular partial-resin base immediate upper/maxillary partial-metal frame immediate lower/mandibular partial-metal frame flexi maxillary partial denture flexi mandibular partial denture 610 Revised December 2018 Page 3 of 4

5 MAJOR CARE (Plan Spcific Benefits) IMPLANT (Only for Plans DN0,DN3 & DN5) Implant Lifetime maximum of $2,200 per individual. Patient must be eligible for six (6) consecutive months before Implant benefit can be used / first and/or second stage of implant (per tooth) surgical placement mini Implant (per tooth) 1, IMPLANT PROCEDURES (Only for Plans DN0,DN3 & DN5 ) Part of the $1,200 prosthetic annual max DN0,DN5 Part of the $1,500 all inclusive max DN implant/abutment complete remv-maxillary 1, implant/abutment complete remv-mandibular 1, implant/abutment partial remv-maxillary implant/abutment partial remv-mandibular implant/abutment complete fixed-maxillary 1, implant/abutment complete fixed-mandibular 1, implant/abutment partial fixed-maxillary 1, implant/abutment partial fixed-mandibular 1, implant connecting bar implant prefabricated abutment implant custom abutment remove broken implant retaining screw implant removal by report Revised December 2018 Page 4 of 4

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