Belk Dental Plan Options

Belk Dental Plan Options Belk Low Plan Deductibles No Deductible for Preventive & Diagnostic Services $ 50 Calendar Year Deductible per person applies to Basic and Major Services Fee Schedule Special Fee Schedule exists for some procedures, excluding Preventive and Ortho services. Members are responsible for the difference between what the plan pays and negotiated contract rate for In Network providers. Deductibles Belk High Plan No Deductible for Preventive & Diagnostics services $100 Lifetime Deductible per person applies to Minor Restorative, Adjunctive, Endodontics, Periodontics and Oral Surgery Services $50 Calendar Year Deductible per person applies to Major Services Incentive (80%/90%/100%) Tier Level Minor Restorative, Adjunctive, Endodontics, Periodontics and Oral Surgery services based on Incentive Tiers: 1st year in plan coverage at 80% of U&C Charges 2nd year in plan coverage at 90% of U&C Charges 3rd year and each following year plan coverage at 100% of U&C Charges 2012 and 2013 Dental claims history from the prior dental carrier loaded for members to administer benefit at correct tier for 2014. If no dental services were received in the previous calendar year, member will revert back to 80% coverage level. Each individual member on the policy must met the above criteria for claims to pay at the appropriate tier

D0140 limited oral evaluation - problem focused $26.16 D0170 re-evaluation, limited, problem focused $26.16 D0472 accession of tissue, gross examination, prep and transmission of $19.62 written report D0473 accession of tissue, gross and microscopic examination, prep and $39.24 transmission of written report D0474 accession of tissue, gross and microscopic exam, includes $39.24 assessment of margins, prep and transmission of report D0486 laboratory accession of transepithelial cytologic sample, micro exam, $19.62 preparation and transmission of written report D2140 amalgam - one surface, primary or permanent $39.24 D2150 amalgam - two surfaces, primary or permanent $55.59 D2160 amalgam - three surfaces, primary or permanent $71.94 D2161 amalgam - four or more surfaces, primary or permanent $85.02 D2330 resin-based composite - one surface, anterior $42.51 D2331 resin-based composite - two surfaces, anterior $65.40 D2332 resin-based composite - three surfaces, anterior $81.75 D2335 resin-based composite - four or more surfaces or involving incisal $81.75 angle (anterior) D2390 resin-based composite crown, anterior $81.75 D2391 resin-based composite - one surface, posterior $45.78 D2392 resin-based composite - two surfaces, posterior $71.94 D2393 resin-based composite - three surfaces, posterior $91.56 D2394 resin-based composite - four or more surfaces, posterior $98.10 D2410 gold foil - one surface $39.24 D2420 gold foil - two surfaces $55.59 D2430 gold foil - three surfaces $71.94 D2510 inlay - metallic - one surface $163.50 D2520 inlay - metallic - two surfaces $261.60 D2530 inlay - metallic - three or more surfaces $294.30 D2542 onlay metallic, two surfaces $310.65 D2543 onlay-metallic-three surfaces $343.35 D2544 onlay-metallic-four or more surfaces $343.35 D2610 inlay - porcelain/ceramic - one surface $163.50 D2620 inlay - porcelain/ceramic - two surfaces $261.60 D2630 inlay - porcelain/ceramic - three or more surfaces $294.30 D2642 onlay - porcelain/ceramic - two surfaces $310.65 D2643 onlay - porcelain/ceramic - three surfaces $343.35 D2644 onlay - porcelain/ceramic - four or more surfaces $343.35 D2650 inlay - composite/resin - one surface $163.50 D2651 inlay - composite/resin - two surfaces $261.60 D2652 inlay - composite/resin - three or more surfaces $294.30 D2662 onlay - composite/resin - two surfaces $310.65 D2663 onlay - composite/resin - three surfaces $343.35 D2664 onlay - composite/resin - four or more surfaces $343.35 D2710 crown,resin-based composite (indirect) $98.10 D2712 crown - 3/4 resin-based composite (indirect) $281.22 D2720 crown - resin with high noble metal $327.00 D2721 crown - resin with predominantly base metal $294.30 Belk Fee Schedule - Low Plan 1 of 8

D2722 crown - resin with noble metal $294.30 D2740 crown - porcelain/ceramic substrate $310.65 D2750 crown - porcelain fused to high noble metal $359.70 D2751 crown - porcelain fused to predominantly base metal $327.00 D2752 crown - porcelain fused to noble metal $327.00 D2780 crown, 3/4 cast high noble metal $327.00 D2781 crown, 3/4 cast predominately base metal $261.60 D2782 crown, 3/4 cast noble metal $261.60 D2783 crown, 3/4 porcelain/ceramic $310.65 D2790 crown - full cast high noble metal $327.00 D2791 crown - full cast predominantly base metal $261.60 D2792 crown - full cast noble metal $261.60 D2794 crown - titanium $327.00 D2910 recement inlay, onlay or partial coverage restoration $32.70 D2915 recement cast or prefabricated post and core $16.35 D2920 recement crown $32.70 D2930 prefabricated stainless steel crown - primary tooth $81.75 D2931 prefabricated stainless steel crown - permanent tooth $81.75 D2932 prefabricated resin crown $81.75 D2933 prefabricated stainless steel crown with resin window $81.75 D2934 prefabricated esthetic coated stainless steel crown - primary tooth $81.75 D2940 protective restoration $22.89 D2950 Core buildup, including any pins when required $52.32 D2951 pin retention - per tooth, in addition to restoration $16.35 D2952 cast post and core in addition to crown $81.75 D2954 prefabricated post and core in addition to crown $81.75 D2980 crown repair necessitated by restorative material failure $78.48 D2981 inlay repair necessitated by restorative material failure $62.13 D2982 onlay repair necessitated by restorative material failure $62.13 D2990 resin infiltration of incipient smooth surface lesions $42.51 D3220 therapeutic pulpotomy (excluding final restoration) $49.05 D3221 pulpal debridement, primary and permanent teeth $49.05 D3222 partial pulpotomy for apexogenesis - permanent tooth with $35.97 incomplete root development D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding $261.60 final restoration) D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding $261.60 final restoration) D3333 internal tooth repair of performation defects $39.24 D3346 retreatment of previous root canal therapy - anterior $261.60 D3347 retreatment of previous root canal therapy - bicuspid $327.00 D3348 retreatment of previous root canal therapy - molar $441.45 D3410 Apicoectomy - anterior $196.20 D3421 Apicoectomy - bicuspid (first root) $196.20 D3425 Apicoectomy - molar (first root) $196.20 D3426 Apicoectomy (each additional root) $49.05 D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $163.50 Belk Fee Schedule - Low Plan 2 of 8

D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth $81.75 bounded spaces per quadrant D4240 gingival flap procedure, including root planning - four or more $228.90 contiguous teeth or tooth bounded spaces per quadrant D4241 gingival flap procedure - including root planing -one to three $114.45 contiguous teeth or tooth bounded spaces per quadrant D4249 clinical crown lengthening - hard tissue $215.82 D4260 osseous surgery (including flap entry and closure) - four or more $215.82 contiguous teeth or tooth bounded spaces per quadrant D4261 osseous surgery (including flap entry and closure) - one to three $222.36 contiguous teeth or tooth bounded spaces per quadrant D4263 Bone replacement graft - first site in quadrant $163.50 D4264 Bone replacement graft - each additional site in quadrant $196.20 D4265 biologic materials to aid in soft and osseous tissue regeneration $81.75 D4270 pedicle soft tissue graft procedure $196.20 D4273 subepithelial connective tissue graft procedures, per tooth $228.90 D4274 distal or proximal wedge procedure (when not performed in $49.05 conjunction with surgical procedures in the same anatomical ar D4275 soft tissue allograft $228.90 D4276 combined connective tissue and double pedicle graft, per tooth $228.90 D4277 free soft tissue graft procedure (including donor site surgery), first $137.34 tooth or edentulous tooth position in graft D4278 free soft tissue graft procedure (including donor site surgery), each $91.56 additiona; D4341 periodontal scaling and root planing - four or more teeth per quadrant $39.24 D4342 periodontal scaling and root planing - one - three teeth, per quadrant $19.62 D4355 full mouth debridement to enable comprehensive evaluation and $26.16 diagnosis D4381 localized delivery of antimicrobial agents via a controlled release $32.70 vehicle into diseased crevicular tissue, per tooth D4910 periodontal maintenance $104.64 D5110 complete denture - maxillary $425.10 D5120 complete denture - mandibular $425.10 D5130 immediate denture - maxillary $425.10 D5140 immediate denture - mandibular $425.10 D5211 maxillary partial denture - resin base (including any conventional $457.80 clasps, rests and teeth) D5212 mandibular partial denture - resin base (including any conventional $457.80 clasps,rests and teeth) D5213 maxillary partial denture - cast metal framework with resin denture $457.80 bases (including any conventional clasps, rests and D5214 mandibular partial denture - cast metal framework with resin denture $457.80 bases (including any conventional clasps, rests and D5225 maxillary partial denture - flexible base (including any clasps, rests $457.80 and teeth) D5226 mandibular partial denture - flexible base (including any clasps, rests and teeth) $457.80 Belk Fee Schedule - Low Plan 3 of 8

D5281 removable unilateral partial denture - one piece cast metal (including $261.60 clasps and teeth) D5410 adjust complete denture - maxillary $16.35 D5411 adjust complete denture - mandibular $16.35 D5421 adjust partial denture - maxillary $16.35 D5422 adjust partial denture - mandibular $16.35 D5510 repair broken complete denture base $39.24 D5520 replace missing or broken teeth - complete denture (each tooth) $32.70 D5610 repair resin denture base $42.51 D5620 repair cast framework $45.78 D5630 repair or replace broken clasp $52.32 D5640 replace broken teeth - per tooth $35.97 D5650 add tooth to existing partial denture $55.59 D5660 add clasp to existing partial denture $78.48 D5670 replace all teeth and acrylic on cast metal framework (maxillary) $457.80 D5671 replace all teeth and acrylic on cast metal framework (mandibular) $457.80 D5710 rebase complete maxillary denture $196.20 D5711 rebase complete mandibular denture $196.20 D5720 rebase maxillary partial denture $147.15 D5721 rebase mandibular partial denture $147.15 D5730 reline complete maxillary denture (chairside) $114.45 D5731 reline complete mandibular denture (chairside) $114.45 D5740 reline maxillary partial denture (chairside) $98.10 D5741 reline mandibular partial denture (chairside) $98.10 D5750 reline complete maxillary denture (laboratory) $196.20 D5751 reline complete mandibular denture (laboratory) $196.20 D5760 reline maxillary partial denture (laboratory) $147.15 D5761 reline mandibular partial denture (laboratory) $147.15 D5810 interim complete denture (maxillary) $196.20 D5811 interim complete denture (mandibular) $196.20 D5820 interim partial denture (maxillary) $130.80 D5821 interim partial denture (mandibular) $130.80 D5850 tissue conditioning, maxillary $49.05 D5851 tissue conditioning, mandibular $49.05 D5860 overdenture - complete, by report $425.10 D5861 overdenture - partial, by report $457.80 D6053 implant/abutment supported removable denture for completely $425.10 edentulous arch D6054 implant/abutment supported removable denture for partially $457.80 edentulous arch D6058 abutment supported porcelain/ceramic crown $310.65 D6059 abutment supported porcelain fused to metal crown (high noble $359.70 metal) D6060 abutment supported porcelain fused to metal crown (predominately $310.65 base metal) D6061 abutment supported porcelain fused to metal crown (noble metal) $310.65 D6062 abutment supported cast metal crown (high noble metal) $327.00 Belk Fee Schedule - Low Plan 4 of 8

D6063 abutment supported cast metal crown (predominately base metal) $294.30 D6064 abutment supported cast metal crown (noble metal) $294.30 D6065 implant supported porcelain/ceramic crown $310.65 D6066 implant supported porcelain fused to metal crown $359.70 D6067 implant supported metal crown $327.00 D6068 abutment supported retainer for porcelain/ceramic FPD $310.65 D6069 abutment supported retainer for porcelain fused to metal FPD (high $359.70 noble metal) D6070 abutment supported retainer for porcelain fused to metal FPD $310.65 (predominately base metal) D6071 abutment supported retainer for porcelain fused to metal FPD (noble $310.65 metal) D6072 abutment supported retainer for cast metal FPD (high noble metal) $327.00 D6073 abutment supported retainer for cast metal FPD (predominately base $294.30 metal) D6074 abutment supported retainer for cast metal FPD (noble metal) $294.30 D6075 implant supported retainer for ceramic FPD $310.65 D6076 implant supported retainer for porcelain fused to metal FPD $359.70 D6077 implant supported retainer for case metal FPD $327.00 D6078 implant/abutment supported fixed denture for completely edentulous $425.10 arch D6079 implant/abutment supported fixed denture for partially edentulous $457.80 arch D6092 recement implant/abutment supported crown $32.70 D6093 recement implant/abutment supported fixed partial denture $32.70 D6094 abutment supported crown - titanium $327.00 D6194 abutment supported retainer crown for FPD - titanium $327.00 D6205 pontic - indirect resin based composite $281.22 D6210 pontic - cast high noble metal $327.00 D6211 pontic - cast predominantly base metal $294.30 D6212 pontic - cast noble metal $294.30 D6214 pontic - titanium $327.00 D6240 pontic - porcelain fused to high noble metal $359.70 D6241 pontic - porcelain fused to predominantly base metal $310.65 D6242 pontic - porcelain fused to noble metal $310.65 D6245 pontic-porcelain/ceramic $310.65 D6250 pontic - resin with high noble metal $261.60 D6251 pontic - resin with predominantly base metal $228.90 D6252 pontic - resin with noble metal $228.90 D6545 retainer - cast metal for resin bonded fixed prosthesis $147.15 D6548 retainer-porcelain/ceramic for resin bonded fixed prosthesis $147.15 D6600 inlay-porcelain/ceramic, two surfaces $261.60 D6601 inlay - porcelain/ceramic, three or more surfaces $287.76 D6602 inlay - cast high noble metal, two surfaces $287.76 D6603 inlay - cast high noble metal, three or more surfaces $317.19 D6604 inlay - cast predominantly base metal, two surfaces $248.52 D6605 inlay - cast predominantly base metal, three or more surfaces $274.68 Belk Fee Schedule - Low Plan 5 of 8

D6606 inlay - cast noble metal, two surfaces $261.60 D6607 inlay - cast noble metal, three or more surfaces $287.76 D6608 onlay - porcelain/ceramic, two surfaces $310.65 D6609 onlay - porcelain/ceramic, three or more surfaces $343.35 D6610 onlay - cast high noble metal, two surfaces $317.19 D6611 onlay - cast high noble metal, three or more surfaces $349.89 D6612 onlay - cast predominantly base metal, two surfaces $274.68 D6613 onlay - cast predominantly base metal, three or more surfaces $300.84 D6614 onlay - cast noble metal, two surfaces $287.76 D6615 onlay - cast noble metal, three or more surfaces $317.19 D6624 inlay - titanium $317.19 D6634 onlay - titanium $349.09 D6710 crown - indirect resin based composite (not to be used as a $281.22 temporary or provisional crown) D6720 crown - resin with high noble metal $327.00 D6721 crown - resin with predominantly base metal $294.30 D6722 crown - resin with noble metal $294.30 D6740 crown-porcelain/ceramic $310.65 D6750 crown - porcelain fused to high noble metal $359.70 D6751 crown - porcelain fused to predominantly base metal $327.00 D6752 crown - porcelain fused to noble metal $327.00 D6780 crown - 3/4 cast high noble metal $310.65 D6781 crown-3/4 cast predominately based metal $261.60 D6782 crown-3/4 cast noble metal $261.60 D6783 crown-3/4 porcelain/ceramic $327.00 D6790 crown - full cast high noble metal $327.00 D6791 crown - full cast predominantly base metal $261.60 D6792 crown - full cast noble metal $261.60 D6794 crown - titanium $327.00 D6930 recement fixed partial denture $39.24 D6940 stress breaker $81.75 D6980 fixed partial denture repair, necessitated by restorative material $160.23 failure D7111 extraction, coronal remnants - deciduous tooth $39.24 D7140 extraction, erupted tooth or exposed root (elevation and/or forceps re $39.24 D7210 surgical removal of erupted tooth req removal of bone,sectioning of $58.86 tooth and including elevation of mucoperiosteal flap D7220 removal of impacted tooth - soft tissue $98.10 D7230 removal of impacted tooth - partially bony $147.15 D7240 removal of impacted tooth - completely bony $179.85 D7241 removal of impacted tooth - completely bony, with unusual surgical $225.63 D7250 surgical removal of residual tooth roots (cutting procedure) $58.86 D7260 oroantral fistula closure $156.96 D7261 primary closure of a sinus perforation $156.96 D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $134.07 Belk Fee Schedule - Low Plan 6 of 8

D7272 tooth transplantation (includes reimplantation from one site to $134.07 another and splinting and/or stabilization) D7280 surgical access of an unerupted tooth $150.42 D7282 mobilization of erupted or malpositioned tooth to aid eruption $150.42 D7283 placement of device to facilitate eruption of impacted tooth $45.78 D7285 biopsy of oral tissue - hard (bone, tooth) $81.75 D7286 biopsy of oral tissue - soft (all others) $81.75 D7287 exfolliative cytological sample collection $42.51 D7288 brush biopsy - transepithelial sample collection $42.51 D7310 alveoloplasty in conjunction with extractions - four or more teeth or $65.40 tooth spaces, per quadrant D7311 alveoplasty in conjunction with extraction - one to three teeth or tooth $32.70 spaces, per quadrant D7320 alveoloplasty not in conjunction with extractions - four or more teeth $114.45 or tooth spaces, per quadrant D7321 alveoplasty not in conjunction with extraction - one to three teeth or $58.86 tooth spaces, per quadrant D7340 vestibuloplasty - ridge extension (secondary epithelialization) $228.90 D7350 vestibuloplasty - ridge extension (including soft tissue grafts, muscle $228.90 reattachment, revision of soft tissue attachment D7410 excision of benign lesion up to 1.25 cm $68.67 D7411 excision of benign lesion greater than 1.25 cm $91.56 D7412 excision of benign lesion, complicated $101.37 D7413 excision of malignant lesion up to 1.25 cm $137.34 D7414 excision of malignant lesion greater than 1.25 cm $153.69 D7415 excision of malignant lesion, complicated $170.04 D7440 excision of malignant tumor-lesion diameter up to 1.25 cm $137.34 D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm $153.69 D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to $68.67 1.25 cm D7451 removal of benign odontogenic cyst or tumor - lesion diameter $91.56 greater than 1.25 cm D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up $68.67 to 1.25 cm D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter $91.56 greater than 1.25 cm D7465 destruction of lesion(s) by physical or chemical method, by report $91.56 D7471 removal of lateral exostosis (maxilla or mandible) $85.02 D7472 removal of torus palatinus $85.02 D7473 removal of torus mandibularis $85.02 D7485 surgical reduction of osseous tuberosity $55.59 D7510 incision and drainage of abscess - intraoral soft tissue $42.51 D7520 incision and drainage of abscess - extraoral soft tissue $91.56 D7530 removal of foreign body from mucosa, skin, or subcutaneous alveolar $68.67 tissue D7540 removal of reaction-producing foreign bodies - musculoskeletal system $91.56 Belk Fee Schedule - Low Plan 7 of 8

D7550 partial ostectomy/sequestrectomy for removal of non-vital bone $91.56 D7560 maxillary sinusotomy for removal of tooth fragment or foreign body $170.04 D7910 suture of recent small wounds up to 5 cm $91.56 D7911 complicated suture - up to 5 cm $120.99 D7912 complicated suture - greater than 5 cm $147.15 D7960 frenulectomy (frenectomy or frenotomy) - separate procedure not $120.99 incidental to another procedure D7963 frenuloplasty $150.42 D7970 excision of hyperplastic tissue - per arch $130.80 D7972 surgical reduction of fibrous tuberosity $49.05 D7980 sialolithotomy $196.20 D7983 closure of salivary fistula $68.67 D9110 palliative (emergency) treatment of dental pain - minor procedure $32.70 D9120 fixed partial denture sectioning $160.23 D9220 deep sedation/general anesthesia - first 30 minutes $81.75 D9221 deep sedation/general anesthesia - each additional 15 minutes $26.16 D9241 intravenous conscious sedation/analgesia - first 30 minutes $55.59 D9242 intravenous conscious sedation/analgesia - each additional 15 $13.08 minutes D9310 consultation (diagnostic service provided by dentist or physician other $39.24 than practitioner providing treatment) D9430 office visit for observation (during regularly scheduled hours) - no $26.16 other services performed D9440 office visit - after regularly scheduled hours $49.05 D9630 other drugs and/or medicaments, by report $19.62 D9911 application of desensitizing resin for cervical and/or root surface, per $42.51 tooth D9951 occlusal adjustment - limited $49.05 D9952 occlusal adjustment - complete $196.20 Belk Fee Schedule - Low Plan 8 of 8