2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees

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1 2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees Schedule effective date for all Plans: January 1, 2018 Annual Deductibles For all Plans: $50 per person /$150 per family each calendar year Annual Maximums Active Plan A Platinum Plus, Platinum, Gold and Uniform Workers (formerly known as Plan G)... $ 1, Active Plan A Silver and Uniform Workers (formerly known as Plan G)... $ 1, Active Plan B Platinum Plus, Platinum and Gold... $ 1, Active Plan B Silver... $ 1, All Retiree Plans... $ 1, Diagnostic and Preventive Deductible waived For all Plans: Plan pays 100% of Schedule Allowance Procedure Code Covered Procedures Oral Evaluations codes , 0321, 0330, X-rays codes , 0480 Tests and Laboratory Examinations codes 1110, 1120, , , 4346 Prophylaxis codes Space Maintenance codes 8999 Orthodontic x-rays/records code (Not covered for Retiree Plans) 9310 Specialist exam/consultation code Basic Restorative For all Plans: Plan pays 80% of Schedule Allowance Procedure Code Covered Procedures Amalgam Fillings codes Resin-Based Composite Restorations codes 2510, Inlay/Onlay/Crown Restorations codes , , , 2952, 2954, , Other Restorative Services codes 3220, , Endodontics codes , 4910 Periodontics codes 6010, 6013, , , Implant Services codes Oral Surgery codes 9110 Palliative (Emergency) treatment code 9230 Analgesia, anxiolysis, nitrous oxide code Major Restorative Procedure Code Covered Procedures , 3427, 3430, 3450, 3920 Endodontics codes , , , Periodontics codes , , , , Prosthodontics, removable codes , , , 6794, 6930, 6980 Prosthodontics, fixed codes 7280, , 7288, , , , , Oral Surgery Codes 7880, 7899, General anesthesia codes 9940 Occlusal guard code DS DE BK Katella Avenue, Cypress, California P.O. Box 6010, Cypress, California scufcwfunds.com 1

2 Indemnity Dental Plan Allowances Diagnostic and Preventive Deductible waived For all Plans: Plan pays 100% of Schedule Allowance 0120 Periodic oral evaluation established patient $ Limited oral evaluation problem focused $ Oral evaluation for a patient under three years of age and counseling with primary caregiver $ Comprehensive oral examination new or established patient $ Detailed and extensive oral examination problem focused, by report $ Re-evaluation limited, problem focused (established patient; not post-operative visit) $ Re-Evaluation post-operative office visit $ Comprehensive periodontal evaluation new or established patient $ Intraoral complete series of radiographic images $ Intraoral periapical first radiographic image $ Intraoral periapical each additional radiographic image $ to maximum of $ Intraoral occlusal radiographic image $ Extraoral, first radiographic image $ Bitewing single radiographic image $ Bitewings two radiographic images $ Bitewings three radiographic images $ Bitewings four radiographic images $ Vertical bitewings 7 to 8 radiographic images $ Other temporomandibular joint radiographic images, by report $ to maximum of $ 1, Panoramic radiographic image $ D oral/facial photographic images obtained intraorally or extraorally $ to maximum of $ D photographic Image $ A Diagnostic Casts $ F Diagnostic Casts $ Q Diagnostic Casts $ Accession of tissue, gross examination, preparation and transmission of written report $ Accession of tissue, gross & microscopic examination, preparation and transmission of written report $ Accession of tissue, gross & microscopic examination, including assessment of surgical margins for presence $ of disease, preparation and transmission of written report 0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission $ of written report 1110 Prophylaxis adult $ Prophylaxis child $ Topical application of flouride varnish $ Topical application of fluoride excluding varnish $ Sealant per tooth $ Preventive resin restoration in a moderate to high caries risk patient permanent tooth $ Space maintainer fixed unilateral $ Space maintainer fixed bilateral $ Space maintainer removable unilateral $ Space maintainer removable bilateral $ Re-cement or re-bond space maintainer $ Distal shoe space maintainer fixed unilateral $ A Scaling in presence of generalized moderate or severe gingival inflammation adult $ C Scaling in presence of generalized moderate or severe gingival inflammation child $ Unspecified orthodontic procedure, by report $ Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician $

3 Basic Restorative For all Plans: Plan pays 80% of Schedule Allowance 2140 Amalgam one surface, primary or permanent $ Amalgam two surfaces, primary or permanent $ Amalgam three surfaces, primary or permanent $ Amalgam four or more surfaces, primary or permanent $ Resin-based composite one surface, anterior $ Resin-based composite two surfaces, anterior $ Resin-based composite three surfaces, anterior $ Resin-based composite four or more surfaces or involving incisal angle (anterior) $ Resin-based composite crown, anterior $ Resin-based composite one surface posterior $ Resin-based composite two surfaces, posterior $ Resin-based composite three surfaces, posterior $ Resin-based composite four or more surfaces, posterior $ Gold Foil one surface $ Gold Foil two surfaces $ Gold Foil three surfaces $ Inlay metallic one surface $ Inlay metallic two surfaces $ Inlay metallic three or more surfaces $ 1, Onlay metallic two surfaces $ Onlay metallic three surfaces $ 1, Onlay metallic four or more surfaces $ 1, Inlay porcelain/ceramic one surface $ Inlay porcelain/ceramic two surfaces $ Inlay porcelain/ceramic three or more surfaces $ 1, Onlay porcelain/ceramic two surfaces $ Onlay porcelain/ceramic three surfaces $ 1, Onlay porcelain/ceramic four or more surfaces $ 1, Inlay resin-based composite one surface $ Inlay resin-based composite two surfaces $ Inlay resin-based composite three or more surfaces $ 1, Onlay resin-based composite two surfaces $ Onlay resin-based composite three surfaces $ 1, Onlay resin-based composite four or more surfaces $ 1, Crown resin-based composite (indirect) $ 1, Crown 3/4 resin-based composite (indirect) $ 1, Crown resin with high noble metal $ 1, Crown resin with predominantly base metal $ 1, Crown resin with noble metal $ 1, Crown porcelain/ceramic substrate $ 1, Crown porcelain fused to high noble metal $ 1, Crown porcelain fused to predominantly base metal $ 1, Crown porcelain fused to noble metal $ 1, Crown 3/4 cast high noble metal $ 1, Crown 3/4 cast predominantly base metal $ 1, Crown 3/4 cast noble metal $ 1, Crown 3/4 porcelain/ceramic $ 1, Crown full cast high noble metal $ 1, Crown full cast predominantly base metal $ 1, Crown full cast noble metal $ 1, Crown titanium $ 1, Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $ Re-cement or re-bond crown $ Reattachment of tooth fragment, incisal edge or cusp $ Prefabricated porcelain/ceramic crown primary tooth $ Prefabricated stainless steel crown primary tooth $ Prefabricated stainless steel crown permanent tooth $ Prefabricated resin crown $ Prefabricated stainless steel crown with resin window $

4 Basic Restorative (continued) For all Plans: Plan pays 80% of Schedule Allowance 2934 Prefabricated esthetic coated stainless steel crown primary tooth $ Restorative foundation for an indirect restoration $ Core build-up, including any pins when required $ Post and core, in addition to crown, indirectly fabricated $ Prefabricated post and core in addition to crown $ Labial veneer (resin laminate) chairside $ Labial veneer (resin laminate) laboratory $ 1, Labial veneer (porcelin laminate) laboratory $ 1, Crown repair necessitated by restorative material failure $ Inlay repair necessitated by restorative material failure $ Onlay repair necessitated by restorative material failure $ Veneer repair necessitated by restorative material failure $ Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction $ and application of medicament 3230 Pulpal therapy (resorable filling) anterior, primary tooth (excluding final restoration) $ Pulpal therapy (resorable filling) posterior, primary tooth (excluding final restoration) $ Endodontic therapy, anterior tooth (excluding final restoration) $ Endodontic therapy, bicuspid tooth (excluding final restoration) $ Endodontic therapy, molar (excluding final restoration) $ 1, Retreatment of previous root canal therapy anterior $ 1, Retreatment of previous root canal therapy bicuspid $ 1, Retreatment of previous root canal therapy molar $ 1, Periodontal scaling and root planing, four or more teeth per quadrant $ Periodontal scaling and root planing, four or more teeth per quadrant $ Periodontal scaling and root planing, four or more teeth per quadrant $ Periodontal scaling and root planing, four or more teeth per quadrant $ Periodontal scaling and root planing, one to three teeth per quadrant $ Periodontal scaling and root planing, one to three teeth per quadrant $ Periodontal scaling and root planing, one to three teeth per quadrant $ Periodontal scaling and root planing, one to three teeth per quadrant $ Periodontal maintenance $ Surgical placement of implant body, endosteal implant $ 2, Surgical placement of mini implants $ 1, Abutment supported porcelain/ceramic crown $ 1, Abutment supported porcelain fused to metal crown (high nobel metal) $ 1, Abutment supported porcelain fused to metal crown (predominantly base metal) $ 1, Abutment supported porcelain fused to metal crown (noble metal) $ 1, Abutment supported cast metal crown (high noble metal) $ 1, Abutment supported cast metal crown (predominantly base metal) $ 1, Abutment supported cast metal crown (noble metal) $ 1, Implant supported porcelain/ceramic crown $ 1, A single metal-ceramic crown restoration that is retained, supported, and stabilized by an implant $ 1, A single cast metal or milled crown restoration that is retained, supported and stabilized by an implant $ 1, Re-cement or re-bond implant/abutment supported crown $ Re-cement or re-bond implant/abutment supported fixed partial denture $ Abutement supported crown (titanium) $ 1, Implant/abutment supported removable denture for edentulous arch maxillary $ 2, Implant/abutment supported removable denture for edentulous arch mandibular $ 2, Implant/abutment supported removable denture for partially edentulous arch maxillary $ 2, Implant/abutment supported removable denture for partially edentulous arch mandibular $ 2, Extraction, coronal remnants deciduous tooth $ Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $ Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, including elevation of $ mucoperiosteal flap if indicated 7220 Removal of impacted tooth soft tissue $ Removal of impacted tooth partially bony $ Removal of impacted tooth completely bony $

5 Basic Restorative (continued) For all Plans: Plan pays 80% of Schedule Allowance 7241 Removal of impacted tooth completely bony, with unusual surgical complications $ Surgical removal of residual tooth roots (cutting procedure) $ Coronectomy intentional partial tooth removal $ Palliative (emergency) treatment of dental pain minor procedure $ Inhalation of nitrous oxide/anxiolysis, analgesia $ Major Restorative 3351 Apexification/recalcification initial visit $ (apical closure/calcific repair of perforations, root reorption, pulp space disinfection, etc.) 3352 Apexification/recalcification interim medication replacement $ Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of $ perforations, root resorption, pulp space disinfection, etc.) 3410 Apicoectomy anterior $ Apicoectomy bicuspid (first root) $ 1, Apicoectomy molar (first root) $ 1, Periradicular surgery without apecoectomy $ Retrograde filling, per root $ Root amputation, per root $ Hemisection (including any root removal), not including root canal therapy $ Gingivectomy/gingivoplasty, four or more contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, four or more contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, four or more contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, four or more contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, one to three contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, one to three contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, one to three contiguous teeth or tooth bounded spaces, per quadrant $ Gingivectomy/gingivoplasty, one to three contiguous teeth or tooth bounded spaces, per quadrant $ Clinical crown lengthening hard tissue $ Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth $ 1, Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth $ 1, Bone replacement graft first site in quadrant $ Bone replacement graft each additional site in quadrant $ Pedicle soft tissue graft procedure $ Subepithelial connective tissue graft procedures, per tooth $ 1,

6 Major Restorative (continued) 4274 Distal or proximal Mesial/distal wedge procedure, single tooth $ (when not performed in conjunction with surgical procedures in the same anatomical area) 4275 Soft tissue allograft $ 1, Combined connective tissue and double pedicle graft, per tooth $ 1, Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft $ Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or endentulous $ tooth position in same graph site 4283 Autogenous connective tissue graft each additional contiguous tooth, implant or edentulous tooth position $ in same graft 4285 Non-autogenous connective tissue graft each additional contiguous tooth, implant or edentulous $ Complete denture maxillary $ 1, Complete denture mandibular $ 1, Immediate denture maxillary $ 1, Immediate denture mandibular $ 1, Maxillary partial denture resin base (including any conventional clasps, rests and teeth) $ 1, Mandibular partial denture resin base (including any conventional clasps, rests and teeth) $ 1, Maxillary partial denture cast metal framework with resin denture bases $ 1, (including any conventional clasps, rests and teeth) 5214 Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ 1, immediate maxillary partial denture resin base $ 1, immediate mandibular partial denture resin base $ 1, immediate maxillary partial denture cast metal framework with resin denture bases $ 1, immediate mandibular partial denture cast metal framework with resin denture bases $ 1, Maxillary partial denture flexible base (includes any clasps, rests and teeth) $ 1, Mandibular partial denture flexible base (includes any clasps, rests and teeth) $ 1, Removable unilateral partial denture one piece cast metal (includes clasps and teeth) $ Repair broken complete denture base mandibular $ Repair broken complete denture base maxillary $ Replace missing or broken teeth, complete denture (each tooth) $ Repair resin denture base mandibular $ Repair resin partial denture base maxillary $ Repair cast partial framework mandibular $ Repair cast partial framework maxillary $ Repair or replace broken clasp $ Replace broken teeth per tooth $ Add tooth to existing partial denture $ Add clasp to existing partial denture $ Replace all teeth and acrylic on cast metal framework (maxillary) $ Replace all teeth and acrylic on cast metal framework (mandibular) $ Rebase complete maxillary denture $ Rebase complete mandibular denture $ Rebase maxillary partial denture $ Rebase mandibular partial denture $ Reline complete maxillary denture (chairside) $ Reline complete mandibular denture (chairside) $ Reline maxillary partial denture (chairside) $ Reline mandibular partial denture (chairside) $ Reline complete maxillary denture (laboratory) $ Reline complete mandibular denture (laboratory) $ Reline maxillary partial denture (laboratory) $ Reline mandibular partial denture (laboratory) $ Interim partial denture (maxillary) $ Interim partial denture (mandibular) $ Tissue conditioning, maxillary $ Tissue conditioning, mandibular $

7 Major Restorative (continued) 5863 Overdenture complete maxillary $ 1, Overdenture partial maxillary $ 1, Overdenture complete mandibular $ 1, Overdenture partial mandibular $ 1, Pontic cast high noble metal $ 1, Pontic cast predominantly base metal $ 1, Pontic cast noble metal $ 1, Pontic titanium $ 1, Pontic porcelain fused to high noble metal $ 1, Pontic porcelain fused to predominantly base metal $ 1, Pontic porcelain fused to noble metal $ 1, Pontic porcelain/ceramic $ 1, Pontic resin with high noble metal $ 1, Pontic resin with predominantly base metal $ 1, Pontic resin with noble metal $ 1, Retainer cast metal for resin bonded fixed prosthesis $ Retainer porcelain/ceramic for resin bonded fixed prosthesis $ Resin retainer for resin bonded fixed prosthesis $ Inlay porcelain/ceramic, two surfaces $ Inlay porcelain/ceramic, three or more surfaces $ 1, Inlay cast high noble metal, two surfaces $ Inlay cast high noble metal, three or more surfaces $ 1, Inlay cast predominantly base metal, two surfaces $ Inlay cast predominantly base metal, three or more surfaces $ 1, Inlay cast noble metal, two surfaces $ Inlay cast noble metal, three or more surfaces $ 1, Onlay porcelain/ceramic, two surfaces $ Onlay porcelain/ceramic, three or more surfaces $ 1, Onlay cast high noble metal, two surfaces $ Onlay cast high noble metal, three or more surfaces $ 1, Onlay cast predominantly base metal, two surfaces $ Onlay cast predominantly base metal, three or more surfaces $ 1, Onlay cast noble metal, two surfaces $ Onlay cast noble metal, three or more surfaces $ 1, Inlay titanium $ 1, Onlay titanium $ 1, Crown resin with high noble metal $ 1, Crown resin with predominantly base metal $ 1, Crown resin with noble metal $ 1, Crown porcelain/ceramic $ 1, Crown porcelain fused to high noble metal $ 1, Crown porcelain fused to predominantly base metal $ 1, Crown porcelain fused to noble metal $ 1, Crown 3/4 cast high noble metal $ 1, Crown 3/4 cast predominantly base metal $ 1, Crown 3/4 cast noble metal $ 1, Crown 3/4 porcelain/ceramic $ 1, Crown full cast high noble metal $ 1, Crown full cast predominantly base metal $ 1, Crown full cast noble metal $ 1, Crown titanium $ 1, Re-cement or re-bond fixed partial denture $ Fixed partial denture repair necessitated by restorative material failure $ Exposure of an unerupted tooth $ Incisional biopsy of oral tissue hard (bone, tooth) $ Incisional biopsy of oral tissue soft $

8 Major Restorative (continued) 7288 Brush biopsy transepithelial sample collection $ Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant $ Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant $ Excision of benign lesion up to 1.25 cm $ Excision of benign lesion greater than 1.25 cm $ Excision of benign lesion, complicated $ Excision of malignant lesion up to 1.25 cm $ Excision of malignant lesion greater than 1.25 cm $ 1, Excision of malignant lesion, complicated $ 1, Excision of malignant tumor lesion diameter up to 1.25 cm $ Excision of malignant tumor lesion diameter greater than 1.25 cm $ 1, Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm $ Removal of benign odontogenic cyst or tumor lesion diameter greater than 1.25 cm $ Removal of benign n onodontogenic cyst or tumor lesion diameter up to 1.25 cm $ Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm $ 1, Removal of lateral exostosis (maxilla or mandible) $ Removal of torus palatinus $ 1, Removal of torus mandibularis $ Incision and drainage of abscess intraoral soft tissue $ Incision and drainage of abscess intraoral soft tissue complicated $ (includes drainage of multiple fascial spaces) 7520 Incision and drainage of abscess extraoral soft tissue $ Incision and drainage of abscess extraoral soft tissue complicated $ (includes drainage of multiple fascial spaces) 7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $ Removal of reaction-producing foreign bodies, musculoskeletal system $ Occlusal orthotic device, by report $ 1, TMJ office visits/unspecified therapy, by report $ to maximum of $ Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental $ to another procedure 7963 Frenuloplasty $ Excision of hyperplastic tissue per arch $ Deep sedation/general anesthesia first 15-minute increment $ Deep sedation/general anesthesia each 15-minute increment $ Occlusal guard, by report $ Supplemental Accident Benefit Deductible waived For all Plans: Plan pays 100% of Schedule Allowance No code Supplemental accident benefit $ Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth and/or alveolus Covered under dental accident expense. 8

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