Schedule of Covered Services and Copayments Family Dental HMO Individual Plan (CA-FD)

Schedule of Covered Services and Copayments Family Dental HMO Individual Plan (CA-FD) D9543 Diagnostic D0120 D0140 D0150 D0160 D0170 D0180 D0190 D0191 D0210 D0220 D0230 D0240 D0250 D0270 D0272 D0273 D0274 D0277 D0330 D0415 D0425 D0460 D0470 Deductible Out of Pocket Maximum - Family Out of Pocket Maximum - Individual Office Visit NC indicates the procedure is not covered periodic oral evaluation - established patient limited oral evaluation - problem focused comprehensive oral evaluation - new or established patient detailed and extensive oral evaluation - problem focused, by report re-evaluation - limited, problem focused (established patient; not post-operative visit) comprehensive periodontal evaluation - new or established patient screening of a patient assessment of a patient intraoral - complete series of radiographic images intraoral - periapical first radiographic image intraoral - periapical each additional radiographic image intraoral - occlusal radiographic image extra-oral 2D projection radiographic image created using a stationary radiation source, and detector bitewing - single radiographic image bitewings - two radiographic images bitewings - three radiographic images bitewings - four radiographic images vertical bitewings - 7 to 8 radiographic images panoramic radiographic image collection of microorganisms for culture and sensitivity caries susceptibility tests pulp vitality tests diagnostic casts None 700 350 D0474 accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report D0601 caries risk assessment and documentation, with a finding of low risk D0602 caries risk assessment and documentation, with a finding of moderate risk D0603 caries risk assessment and documentation, with a finding of high risk Preventive D1110 D1120 D1206 D1208 D1310 D1330 D1351 D1352 prophylaxis - adult (limited to 1 per 6 months & additional at higher copayments) prophylaxis - child (limited to 1 per 6 months & additional at higher copayments) topical application of fluoride varnish topical application of fluoride excluding varnish nutritional counseling for control of dental disease oral hygiene instructions sealant - per tooth preventive resin restoration in a moderate to high caries risk patient permanent tooth Space Maintainers D1510 D1515 D1520 D1525 D1550 D1555 space maintainer - fixed - unilateral space maintainer - fixed - bilateral space maintainer - removable - unilateral space maintainer - removable - bilateral re-cement or re-bond space maintainer removal of fixed space maintainer Amalgam Restorations - Primary or Permanent D2140 D2150 D2160 amalgam - one surface, primary or permanent amalgam - two surfaces, primary or permanent amalgam - three surfaces, primary or permanent

D2161 amalgam - four or more surfaces, primary or permanent Resin-Based Composite Restorations D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 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 Crowns - Single Restoration Only Base Metal is the benefit; Additional fees of $125 for noble /$150 for high noble, $100 for porcelain on molars, $50 for porcelain butt margin, and $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc. apply. D2543 onlay - lic - three surfaces D2544 onlay - lic - four or more surfaces D2710 crown - resin-based composite (indirect) D2740 crown - porcelain/ceramic substrate D2750 crown - porcelain fused to high noble D2751 crown - porcelain fused to predominantly D2752 crown - porcelain fused to noble D2780 crown - 3/4 cast high noble D2781 crown - 3/4 cast predominantly base D2782 crown - 3/4 cast noble D2783 crown - 3/4 porcelain/ceramic D2790 crown - full cast high noble D2791 crown - full cast predominantly D2792 crown - full cast noble Other Restorative Services D2910 D2915 D2920 re-cement or re-bond inlay, onlay, veneer or partial coverage restoration re-cement or re-bond indirectly fabricated or prefabricated post and core re-cement or re-bond crown D2929 prefabricated porcelain/ceramic crown 60 60 primary tooth D2930 prefabricated stainless steel crown - 60 60 primary tooth D2931 prefabricated stainless steel crown - 60 60 permanent tooth D2932 prefabricated resin crown 60 60 D2933 prefabricated stainless steel crown with 80 80 resin window D2934 prefabricated esthetic coated stainless 80 80 steel crown - primary tooth D2940 protective restoration D2950 core buildup, including any pins when required D2951 pin retention - per tooth, in addition to 20 20 restoration D2952 post and core in addition to crown, indirectly fabricated D2954 prefabricated post and core in addition to 55 crown D2955 post removal 55 D2980 crown repair necessitated by restorative 60 60 material failure D2981 inlay repair necessitated by restorative 20 20 material failure D2982 onlay repair necessitated by restorative 20 20 material failure D2990 resin infiltration of incipient smooth 2 2 surface lesions Endodontics D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 pulp cap - direct (excluding final pulp cap - indirect (excluding final therapeutic pulpotomy (excluding final - removal of pulp coronal to the dentinocemental junction and application of medicament pulpal debridement, primary and permanent teeth partial pulpotomy for apexogenesis - permanent tooth with incomplete root development pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final endodontic therapy, anterior tooth (excluding final endodontic therapy, bicuspid tooth (excluding final 12 12 6 6 60 60

D3330 endodontic therapy, molar (excluding final D3346 retreatment of previous root canal therapy - anterior D3347 retreatment of previous root canal therapy - bicuspid D3348 retreatment of previous root canal therapy - molar D3351 apexification/recalcification initial visit 22 22 (apical closure / calcific repair of perforations, root resorption, etc.) D3352 apexification/recalcification interim 22 22 medication replacement D3353 apexification/recalcification - final visit 22 22 (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) D3410 apicoectomy - anterior 75 75 D3421 apicoectomy - bicuspid (first root) 75 75 D3425 apicoectomy - molar (first root) 75 75 D3426 apicoectomy (each additional root) 75 75 D3430 retrograde filling - per root 45 45 Periodontics D4210 D4211 D4212 D4240 D4241 D4260 D4261 D4341 D4342 D4355 D4910 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded periodontal scaling and root planing - four or more teeth per quadrant periodontal scaling and root planing - one to three teeth per quadrant full mouth debridement to enable comprehensive evaluation and diagnosis periodontal maintenance (first 2 cleanings within calendar year) 150 150 150 150 200 200 200 200 Dentures Dentures and partials include four months free adjustments. Add lab cost of any gold. D5110 complete denture - maxillary D5120 complete denture - mandibular D5130 immediate denture - maxillary D5140 immediate denture - mandibular D5211 maxillary partial denture - resin base D5212 mandibular partial denture - resin base D5213 maxillary partial denture - cast framework with resin denture bases D5214 mandibular partial denture - cast framework with resin denture bases D5225 maxillary partial denture - flexible base (including any clasps, rests D5226 mandibular partial denture - flexible base (including any clasps, rests D5281 removable unilateral partial denture - one piece cast (including clasps and teeth) Denture Adjustments & Repairs D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 adjust complete denture - maxillary adjust complete denture - mandibular adjust partial denture - maxillary adjust partial denture - mandibular repair broken complete denture base replace missing or broken teeth - complete denture (each tooth) repair resin denture base repair cast framework repair or replace broken clasp - per tooth replace broken teeth - per tooth add tooth to existing partial denture add clasp to existing partial denture - per tooth 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) 20 20 20 20

D5740 reline maxillary partial denture (chairside) D5741 reline mandibular partial denture (chairside) D5750 reline complete maxillary denture 95 95 (laboratory) D5751 reline complete mandibular denture 95 95 (laboratory) D5760 reline maxillary partial denture (laboratory) 95 95 D5761 reline mandibular partial denture 95 95 (laboratory) D5821 interim partial denture (mandibular) 90 90 D5821 interim partial denture (mandibular) 90 90 D5850 tissue conditioning, maxillary D5851 tissue conditioning, mandibular D5863 overdenture complete maxillary D5864 overdenture partial maxillary D5899 unspecified removable prosthodontic procedure, by report Bridges Base Metal is the benefit; Additional fees of $125 for noble /$150 for high noble, $100 for porcelain on molars, $50 for porcelain butt margin, and $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc. apply. D6210 pontic - cast high noble D6211 pontic - cast predominantly D6212 pontic - cast noble D6214 pontic - titanium D6240 pontic - porcelain fused to high noble D6241 pontic - porcelain fused to predominantly D6242 pontic - porcelain fused to noble D6610 retainer onlay - cast high noble, two surfaces D6611 retainer onlay - cast high noble, three or more surfaces D6612 retainer onlay - cast predominantly base, two surfaces D6613 retainer onlay - cast predominantly base, three or more surfaces D6614 retainer onlay - cast noble, two surfaces D6615 retainer onlay - cast noble, three or more surfaces D6740 retainer crown - porcelain/ceramic D6750 retainer crown - porcelain fused to high noble D6751 retainer crown - porcelain fused to predominantly D6752 retainer crown - porcelain fused to noble D6780 retainer crown - 3/4 cast high noble D6781 retainer crown - 3/4 cast predominantly D6782 retainer crown - 3/4 cast noble D6783 retainer crown - 3/4 porcelain/ceramic D6790 retainer crown - full cast high noble D6791 retainer crown - full cast predominantly D6792 retainer crown - full cast noble D6794 retainer crown - titanium D6930 re-cement or re-bond fixed partial denture 12 12 D6980 fixed partial denture repair necessitated by restorative material failure Oral Surgery D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7285 D7286 D7288 D7311 D7320 D7321 D7410 D7411 D7412 D7450 D7451 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, and including elevation of mucoperiosteal flap if indicated removal of impacted tooth - soft tissue removal of impacted tooth - partially bony removal of impacted tooth - completely bony removal of impacted tooth - completely bony, with unusual surgical complications surgical removal of residual tooth roots (cutting procedure) incisional biopsy of oral tissue-hard (bone, tooth) incisional biopsy of oral tissue-soft brush biopsy - transepithelial sample collection alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant 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 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 65 65 50 50 60 60 80 80 160 160 160 160 50 50 80 80 75 75

D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm D7471 removal of lateral exostosis (maxilla or mandible) D7472 removal of torus palatinus D7510 incision and drainage of abscess - intraoral soft tissue D7511 incision and drainage of abscess - 50 50 intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) D7520 incision and drainage of abscess - extraoral soft tissue D7521 incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) D7910 suture of recent small wounds up to 5 cm D7911 complicated suture - up to 5 cm D7912 complicated suture - greater than 5 cm D7960 frenulectomy - also known as frenectomy 165 165 or frenotomy - separate procedure not incidental to another procedure D7963 frenuloplasty 165 165 D9440 office visit - after regularly scheduled hours D9951 occlusal adjustment - limited Orthodontics Only medically necessary orthodontia is covered. Medically Necessary Orthodontia is for Cleft palate; Cleft palate with cleft lip and the following anomalies: Hemifacial microsmia; Craniosynostosis syndromes; Cleidocranial dental dysplasia; Arthrogryposis; Marfan syndrome. Must be preauthorized. 35 Please call your Dental Health Services Member Service Specialist at 855-495- 0905 for a referral to a conveniently located participating orthodontist. Orthodontic models, x-rays, photographs and records are not covered. There may be additional copayments depending on treatment needs. Other Services Iv sedation/general anesthesia is per person, per year. Inhalation of nitrous oxide/analgesia is per person, per visit. D9110 palliative (emergency) treatment of dental pain - minor procedure D9211 regional block anesthesia D9212 trigeminal division block anesthesia D9215 local anesthesia in conjunction with operative or surgical procedures D9230 inhalation of nitrous oxide/analgesia, 50% up 50% up anxiolysis D9248 non-intravenous conscious sedation 50% up 50% up D9310 D9410 D9420 D9430 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician house/extended care facility call hospital or ambulatory surgical center call office visit for observation (during regularly scheduled hours) - no other services performed 20 20 200 200 250 250

Exclusions and Limitations Family Dental HMO Individual Plan Orthodontic Exclusions The following services are not covered by your dental plan: A. Retreatment of orthodontic cases. B. Treatment of a case in progress at inception of eligibility. C. Surgical procedures (including extraction of teeth) incidental of orthodontic treatment. D. Surgical procedures related to cleft palate, micrognathia or macrognathia. E. Treatment related to temporomandibular joint (TMJ) disturbances and/or hormonal imblances. F. Any dental procedure considered within the field of general dentistry including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation dental services of any nature performed in a hospital. G. Cephalometric x-rays, dental x-rays. H. Tracings and photographs. I. Study models. J. Replacement of lost or broken appliances. K. Changes in treatment necessitated by an accident of any kind. L. Payment by Dental Health Services or any special discounted orthodontic copayment for treatment rendered or required after the enrollee is no longer eligible for coverage (i.e. current premium unpaid). The cost of treatment in progress will be prorated and converted to the Orthodontist s actual fee-for service amount. Orthodontic Limitations The following are subject to additional charges: A. Orthodontia is limited to medically necessary orthodontic cases. B. Services which are compensable Worker s Compensation or employer liability laws. C. Malocclusions so severe or mutilated they are not amenable to ideal orthodontic therapy. D. Most medically-necessary orthodontia requires treatment lasting 24 months. If the contract between Dental Health Services and the enrollee should terminate, copayments will be prorated. Dental Exclusions The following services are not covered by your dental plan: A. Services that are not consistent with professionally recognized standards of practice. B. Cosmetic services, for appearance only, unless specifically listed. C. Myofunctional therapy-procedures for training, treating or developing muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard. D. Treatment for malignancies, as well as hereditary, congenital and/or developmental malformations. E. Dispensing of drugs not normally supplied in a dental office. F. Hospitalization charges, dental procedures or services rendered while patient is hospitalized. G. Procedures, appliances or restorations (other than fillings) that are necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 10 crowns/pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion. H. Procedures performed by a prosthodontist. I. Fixed bridges for patients the age of sixteen, in the presence of non-supportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth in an arch, replacement of missing third molars, or when the prognosis is poor. J. Dental procedures that cannot be performed in the dental office due to the general health and/or physical limitations of the member. K. Expenses incurred for dental procedures initiated prior to member s eligibility with Dental Health Services, or after termination of eligibility. L. Services that are reimbursed by a third party (such as the medical portion of an insurance/health plan or any other third party indemnification). M. Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures. N. Coordination of benefits with another prepaid managed care dental plan. O. Orthodontic treatment of a case in progress and/or retreatment of ortho cases, excluding Medically Necessary Orthodontia cases which are a covered benefit. P. Cephalometric x-rays, tracings, photographs and orthodontic study models. Q. Replacement of lost or broken orthodontic appliances. R. Changes in orthodontic treatment necessitated by an accident of any kind. S. Malocclusions so severe or mutilated which are not amenable to ideal orthodontic therapy. T. Services not specifically listed or listed as NC (not covered) in the Schedule of Covered Services and Copayments. Dental limitations Restrictions on benefits are applied to the following services: A. Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms and does not cover definitive restorative treatment including, but not limited to root canal treatment and crowns. B. Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient. C. Prophylaxis services (cleanings) are limited to two (2) in a twelve (12)-month period. D. Full mouth x-rays are limited to one set every two years if needed. E. Specialty referrals must be pre-approved by Dental Health Current Dental Terminology 2015 American Dental Association. All rights reserved.

Services for any treatment deemed necessary by the treating participating dentist. F. Pre-authorization is required for all specialty services. G. Periodontal scaling and root planing, and subgingival curettage are limited to five (5) quadrant treatments in any twelve (12) consecutive months. H. Sealants are only a benefit for permanent posterior teeth of children the age of eighteen. I. There are additional charges for precious/noble s (gold). J. Partial dentures will not be replaced within thirty-six (36) consecutive months unless: 1. It is necessary due to natural tooth loss where the addition or replacement of teeth to the existing parial is not feasible; or 2. The denture is unsatisfactory and cannot be made satisfactory. K. Full upper and/or lower dentures are not to be replaced within thirty-six (36) consecutive months unless the existing denture is unsatisfactory and cannot be made satisfactory by reline or repair. L. Office or laboratory relines or rebases are limited to one (1) per arch in any twelve (12) consecutive months. M. Crowns will be covered only when the teeth cannot be adequately restored with other restorative materials. Replacement of each unit is limited to once every thirty-six (36) consecutive months, except when the crown is no longer functional as determined by Dental Health Services. N. Fixed bridges will be used only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment. 1. Fixed bridges used to replace missing posterior teeth are considered optional when the abutment teeth are dentally sound and would be crowned only for the purpose of supporting a pontic. 2. Fixed bridges are optional when provided in connection with a partial denture on the same arch. 3. Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair. O. I.V. sedation/general anesthesia is per person, per year. Inhalation of nitrous oxide/analgesia is per person, per visit. Dental Health Services A Great Reason to Smile sm 3833 Atlantic Avenue, Long Beach, CA 90807 855-495-0905 www.dentalhealthservices.com 2015 Dental Health Services