Dental Fee Schedule Dental Advantage Essentials. What is the out-of-pocket limit? Primary care dentist

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1 Dental Fee Schedule Dental Advantage Essentials This plan covers dental services for enrolled individuals age 18 and younger, as required under the Affordable Care Act. Out-of-Pocket Limit $350 per person / $700 for two or more people per calendar year for enrolled individuals age 18 and younger. What is the out-of-pocket limit? The out-of-pocket limit is the most you ll pay for approved dental expenses during the calendar year and applies to enrolled individuals age 18 and younger on your policy. Once the out-of-pocket limit has been met, the plan will pay 100 percent of covered charges for the rest of that year. Primary care dentist You must select a Dental Advantage Essentials Network dentist as your primary care dentist (PCD) from the plan s provider directory. The PCD will coordinate all of your dental care needs. See your Dental Member Handbook for details. The member is responsible for any amounts shown above, in addition to the following amounts. ADA Code Procedure Co-payment General Office Visit Charge $25 Specialist Office Visit Charge $30 Emergency Office Visit Charge $50 Diagnostic and Preventive Services D Periodic oral evaluation D Limited oral evaluation - problem focused D Oral evaluation - patient under three years old + D Comprehensive oral evaluation D Detailed and extensive oral evaluation D Re-evaluation - limited D Re-evaluation - post operative office visit D Comprehensive periodontal evaluation D Assessment of a patient D Complete series x-rays D Periapical - first film D Intraoral - each additional film D Intraoral - occlusal film D Extraoral - 2D projectio D Extraoral - posterior dental radiographic image D Bitewings - single film D Bitewings - two films D Bitewings - three films A

2 D Bitewings - four films D Vertical bitewings D Sialography + D TMJ arthrogram + D Other TMJ films + D Tomographic survey + D Panoramic x-rays D0340 2D cephalometric film D Oral/facial images D Cone beam CT, limited view D Cone beam CT, full arch-mandible D Cone beam CT, full arch-maxilla D Cone beam CT, both jaws D Cone beam CT, TMJ series D Interpret and report diagnostic image + D Collection for culture and sensitivity + D Caries susceptibility test D Pulp vitality test D Diagnostic casts D Teeth cleaning (prophylaxis) - adult D Teeth cleaning (prophylaxis) - child + D Topical fluoride - therapeutic application D Topical fluoride D Nutritional counseling D Tobacco counseling D Oral hygiene instruction D Sealant - per tooth D Sealant repair - per tooth D Interim caries arresting medicament application Not covered Not covered Not covered Space Maintainers D Space maintainer - unilateral - fixed D Space maintainer - bilateral - fixed D Space maintainer - unilateral - removable D Space maintainer - bilateral removable D Space maintainer - re-cement D Removal of fixed space maintainer Restorative Dentistry Amalgam Restorations D Fillings - one surface D Fillings - two surfaces D Fillings - three surfaces D Fillings - four or more surfaces B

3 D Sedative filling - temporary D Pin retention - per tooth, in addition to restoration Resin Restorations D Resin - one surface anterior D Resin - two surfaces anterior D Resin - three surfaces anterior D Resin - four or more surfaces anterior D Resin based composite crown D Resin - one surface posterior - primary D Resin - one surface posterior - permanent $60 D Resin - two surfaces posterior - primary D Resin - two surfaces posterior - permanent $60 D Resin - three surfaces posterior - primary D Resin - three surfaces posterior - permanent $60 D Resin - four or more surfaces posterior - primary D Resin - four or more surfaces posterior - permanent $60 D Core buildup, including any pins if after corresponding root canal Inlay/Onlay (cast restorations) D Inlay - gold - one surface $200 D Inlay - gold - two surfaces $200 D Inlay - gold - three or more surfaces $200 D Onlay - gold - two surfaces $200 D Onlay - gold - three surfaces $200 D Onlay - gold - four or more surfaces $200 D Inlay - porcelain/ceramic - one surface $200 D Inlay - porcelain/ceramic - two surfaces $200 D Inlay - porcelain/ceramic - three or more surfaces $200 D Onlay - porcelain/ceramic - two surfaces $200 D Onlay - porcelain/ceramic - three surfaces $200 D Onlay - porcelain/ceramic - four or more surfaces $200 D Re-cement inlay Crowns D Crown - resin laboratory $200 D Crown - ¾ resin based composite $200 D Crown - porcelain/ceramic anterior $200 D Crown - porcelain fused to predominantly base metal D Crown - porcelain/noble $200 D Crown - ¾ cast - noble $200 D Crown full cast noble $200 D Provisional crown C

4 D Re-cement cast or prefabricated post and core D Re-cement crown D Stainless steel crown - primary D Stainless steel crown - permanent D Crown - prefabricated resin D Crown - prefabricated stainless steel with resin window D Prefabricated post and core D Post removal (no endodontic therapy) D Each additional prefabricated post - same tooth D Repair crown Endodontics D Pulp cap - direct excluding final restoration D Pulp cap - indirect excluding final restoration D Pulpotomy - A pulpotomy is not the first stage of a root canal. A pulpotomy is a separate procedure D Gross pulpal debridement - primary and permanent D Partial pulpotomy for apexogenesis + D Pulpal therapy - primary anterior D Pulpal therapy - primary posterior D Root canal therapy - anterior $200 D Root canal therapy - bicuspid $200 D Root canal therapy - molar $200 D Treatment of root canal obstruction - non-surgical access D Incomplete endodontic therapy - inoperable or fractured tooth D Internal repair of perforation defects D Retreatment - anterior $200 D Retreatment - bicuspid $200 D Retreatment - molar $200 D Apexification - initial visit $200 D Apexification - interim visit D Apexification - final visit D Apicoectomy - anterior $200 D Apicoectomy - bicuspid first root $200 D Apicoectomy - molar first root $200 D Apicoectomy - each additional root D Retrograde filling - per root D Root amputation per root $200 D Hemisection $200 D Canal prep-preformed dowel/post D

5 Note: The treatment of a root canal or apical surgery performed within 24 months of initial treatment is considered part of the initial treatment charge. Thereafter, re-treatment of a root canal may be subject to an additional charge. Periodontics D Gingivectomy or gingivoplasty - four or more D Gingivectomy - one to three D Gingival flap - four or more $200 D Gingival flap - one to three $200 D Crown lengthening hard tissue $200 D Osseous surgery - four or more $200 D Osseous surgery - one to three $200 D Bone replacement graft - first site in quadrant $200 D Bone replacement graft - each additional site in quadrant D Pedicle soft tissue graft procedure $200 D Autogenous connective tissue graft $200 D Distal wedge procedure $200 D Free soft tissue graft procedure $200 D Periodontal scale and root plane - four or more D Periodontal scale and root plane - one to three D Full-mouth debridement D Antimicrobial irrigation D Periodontal maintenance following therapy D Unscheduled dressing change + Prosthodontics - Removable D Complete (upper denture) D Complete (lower denture) D Immediate (upper denture) D Immediate (lower denture) D Upper partial resin base D Lower partial resin base D Upper partial cast metal frame D Lower partial cast metal fram D Immediate maxillary partial denture - resin base D Immediate mandibular partial denture - resin base D Immediate maxillary partial denture - cast metal framework with resin denture bases D Immediate mandibular partial denture - cast metal framework with resin denture bases E

6 D Upper partial flexible base + D Lower partial flexible base + D Partial - removable unilateral + D Adjustment - complete denture, upper D Adjustment - complete denture, lower D Adjustment - partial denture, upper D Adjustment - partial denture, lower D Repair broken denture no damaged D Repair denture replace missing or broken (each tooth) D Repair resin base D Repair partial cast framework D Repair or replace partial clasp D Replace - partial per tooth D Add tooth to existing partial D Add clasp to existing partial D Replace all -maxillary + D Replace all -mandibular + D Rebase complete upper denture D Rebase complete lower denture D Rebase upper partial D Rebase lower partial D Reline complete upper denture (chairside) D Reline complete lower denture (chairside) D Reline upper partial (chairside) D Reline lower partial (chairside) D Reline upper denture - lab D Reline lower denture - lab D Reline upper partial - lab D Reline lower partial - lab D Interim denture - upper $100 D Interim denture - lower $100 D Interim partial - upper 1 x 5 years $100 D Interim partial - lower 1 x 5 years $100 D Tissue conditioning - upper D Tissue conditioning - lower D Fluoride gel custom tray Prosthodontics - Fixed D Pontic, cast (per tooth) traditional fixed partial dentures only (bridges) $200 D Pontic (per tooth); porcelain/metal traditional fixed $200 partial dentures only (bridges) D Pontic (per tooth) maryland bridge $200 F

7 D Cast metal retainer $200 D Resin retainer - for resin bonded fixed prosthesis + $200 D Retainer crown - resin/metal abutment $200 D Retainer crown - porcelain metal abutment $200 D Retainer crown - ¾ cast metal abutment $200 D Retainer crown - full gold abutment $200 D Re-cement bridge D Coping - metal D Bridge repair Oral Surgery D Extraction coronal remnants primary tooth D Extraction erupted tooth D Surgical extraction - erupted D Removal of impacted tooth - soft tissue D Removal of impacted tooth - partial bony D Removal of impacted tooth - complete bony D Removal of impacted tooth - complete bony with complications D Surgical removal residual root D Coronectomy-intentional partial tooth removal + D Oroantral fistula closure D Primary closure of sinus perforation + D Tooth re-implantation D Surgical access unerupted tooth D Ortho bracket to aid eruption if plan covers orthodontia D Biopsy of oral tissue-hard + D Biopsy of oral tissue-soft + D Exfoliative cytological sample collection + D Brush biopsy D Transseptal fiberotomy D Alveoloplasty with extractions - per quadrant D Alveoloplasty without extractions - per quadrant D Alveoloplasty not in conjunction with extraction-1 to 3 D Vestibuloplasty ridge extension D Vestibuloplasty ridge extension w/graft D Remove benign odontogenic cyst-<=1.25cm D Remove benign odontogenic cyst->1.25cm D Destruction of lesion-physical or chemical method D Remove lateral exostosis D I and D intraoral soft tissue D I and D extraoral soft tissue G

8 D Remove foreign body - soft tissue D Remove foreign body - hard tissue D Partial ostectomy/sequestrectomy non vital bone + D Maxillary sinusotomy + D Stabilization splint-alveolus D Compound fracture-alveolus closed reduction + D Suture small wound up to five cm + D Complicated suture up to five cm + D Suture complicated.5 cm D Osteoplasty D Bone replacement graft for ridge reservation - per site D Frenectomy D Frenuloplasty + D Excision hyperplastic tissue D Excision of pericoronal flap D Sialolithotomy + D Excision of salivary gland + D Sialodochoplasty + D Closure of salivary fistula + D Emergency tracheotomy + D Appliance removal + Orthodontia D Limited orthodontic primary dentition + D Limited orthodontic transitional dentition + D Limited orthodontic adolescent dentition + D Limited orthodontic adult dentition + D Interceptive orthodontic primary dentition + D Interceptive orthodontic transitional dentition + D Comprehensive orthodontic transitional dentition $3,000 D Comprehensive orthodontic adolescent dentition $3,000 D Comprehensive orthodontic adult dentition $3,000 D Removable appliance therapy + D Fixed appliance therapy + D Pre-orthodontic visit ^ D Periodic orthodontic visit D Orthodontic retention D Removable orthodontic device adjustment D Orthodontic treatment - alternative billing + D Repair of orthodontic appliance + D Re-bonding or re-cementing; or repair H

9 Anesthesia D Fix partial denture sectioning + D Local Anesthesia not in conjunction with operative or surgical procedures + D Regional block anesthesia + D Trigeminal block anesthesia + D Local anesthesia (Novocain) D Deep sedation/general anesthesia - each 15 minute increment + D Nitrous oxide (per visit) $20 Miscellaneous D Palliative (emergency) minor D Intravenous moderate (conscious) sedation/analgesia-each 15 minute increment + D Non-intravenous conscious sedation + D Consultation - per session D House/LTC facility call + D Hospital call (dental treatment provided in a hospital setting in addition to any other applicable service co-pays; facility fees not covered) (service $100 co-pays still apply) D Observation visit D Emergency treatment - after office hours $25 D Therapeutic parenteral drug - single admin + D Therapeutic parenteral drug-2 or > admin + D Other drugs or meds + D Application of desensitizing medicaments D Behavior management + D Treatment of complications - unusual circumstances + D Occlusal adjustment - simple D Occlusal adjustment - complete Out-of-area emergency reimbursement + Reimbursed up to $100 Exclusions See Exclusion section of the Member Handbook ^ Fee credited toward comprehensive orthodontic co-payment, if patient accepts treatment plan. + Not covered for enrolled individuals age 19 years and older. I

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