DENTAL DIRECTORY SERVICES Fee Schedule A

1 SPECIALIST SERVICESas performed by Board Eligible or Board Certified DENTAL specialistsCODE DDSAT ypicalCost*You SAVEORAL SURGERYD7111 Extraction, coronal remnants deciduous tooth$99 $170 $67 D7140 Extraction erupted tooth or exposed root (elevation and/or forceps removal)$103 $201 $98 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth - each tooth$134 $297 $163 D7220 Removal of impacted tooth-soft tissue$173 $339 $166 D7230 Removal of impacted tooth-partially bony$212 $424 $212 D7240 Removal of impacted tooth-completely bony$257 $479 $222 D7241 Removal of impacted tooth - completely bony with unusual surgical complications$314 $557 $243 D7250 Surgical removal of residual tooth roots (cutting procedure)$162 $352 $190 D7280 Surgical access of an unerupted tooth$223 $318 $95 D7310 Alveolectomy or plasty in conjunction with extractions - per quadrant$134 $382 $248 D7320 Alveolectomy or plasty not in conjunction with extractions - per quadrant$180 $602 $422 D7960 Frenulectomy (frenectomy or frenotomy), separate procedure$212 $557 $345 D7970 Excision of hyperplastic tissue - per arch$253 $795 $542 D7971 Excision of pericoronal gingiva$142 N/AN/ASurgical procedures listed above include the administration of local anesthesia only.

2 The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at additional cost to the participating PROCEDURESD4210 Gingivectomy or gingivoplasty, 4+ contiguous teeth/quad$356 $1,060 $704 D4211 Gingivectomy or gingivoplasty, 1-3 contiguous teeth/quad$151 $890 $739 D4240 Gingival flap procedure-incl root planing, per quadrant$435 N/AN/AD4260 Osseous surgery-incl flap entry and closure, per quadrant$613 $1,685 $1,072 D4270 Pedicle soft tissue graft procedure$360 N/AN/AD4341 Periodontal scaling and root planing, per quadrant$152 $356 $204 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis$112 $148 $70 D4910 Periodontal maintenance procedures (following active therapy)$78 $140 $79 ENDODONTIC PROCEDURESD3310 Root Canal therapy-anterior (excl final restoration)$399 $1,007 $608 D3320 Root Canal therapy-bicuspid (excl final restoration)$473 $1,087 $614 D3330 Root Canal therapy-molar (excl final restoration)$618 $1,325 $707 D3410 Apicoectomy (per tooth) - first root$356 $1,105 $749 D3426 Apicoectomy (per tooth) - each additional tooth$145 N/AN/AD3430 Retorgrade filling - per root$139 N/AN/AD3450 Root amputation - per root$178 N/AN/AD3920 Hemisection (incl.)

3 Root removal; excl. root canal therapy)$200 N/AN/ACODE DDSAT ypicalCost*You SAVEORTHODONTICS - COMPREHENSIVE CASE, CLASS 1, 11, 111 (up to and including age 16) D8070, D8080 Orthodontic records, treatment plan and consultation$112 N/AN/AInitial ortho. appliance, construction and installation$428 N/AN/AActive treatment phase - up to 24 months$2,587 N/AN/ARetention phase per retainer$210 N/AN/ATotal for those up to and including age 16$3,338 $5,809 $2,471 Continuation of orthodontic treatment beyond 24 months and other orthodontic SERVICES available at a 25% discount from usual and customary fees charged by orthodontists listed in the DDS DENTAL DIRECTORY . Orthodontic treatment includes the treatment of primary, transitional, and/or adolescent dentitions under the D8000-D8999 series procedure codes. Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee.

4 Invisalign braces are 25% off the usual and customary fee of the participating DIRECTORY SERVICES (DDS), TERMS AND DENTAL SERVICES appearing in this Schedule are available from generapractitioners and specialists listed in the DDS DENTAL DIRECTORY . Anyservices that are not listed are available at a 25% discount from usualand customary fees charged by participating general practitioners andspecialists, including pedodontics, prosthodontics and from the Annual Check-up, additional exams, x-rays andconsultations are available at a 25% discount at general exams, x-rays and consultations at all specialists are 25% of thedentist s usual and customary fee. Invisalign braces are 25% of thedentist usual and customary participating providers may charge an OSHA sterilization fee pervisit and a lab fee for crown, bridges and denture administration of nitrous oxide intravenous sedation or generalanesthesia is available at a 25% discount from usual and customary feescharged by the participating general practitioners and is not a covered is the Member s responsibility to verify that the dentist is a participatingProvider for DDS before seeking any treatment.

5 Any DENTAL proceduresperformed by a non-participating dentist are not dollar amount specified for each procedure may not be the onlycost incurred for a given treatment. Many treatments may require morethan one DENTAL procedure. Please consult with your DDS provider fora detailed treatment plan before beginning any DENTAL can not guarantee the continued participation of any dentist. Ifthe dentist that you use leaves the plan, you will need to select anotherparticipating provider. Not all DENTAL specialists are available in participating DDS providers are professionally licensed in thestate in which they practice, DDS does not guarantee the quality ofservice of the providers. Any quality of care concerns involving anyparticipating provider should be directed to the DDS Provider listings and/or fee schedules can be updated or changedwithout notice.*Typical cost provided by ADA DENTAL Survey 2006, 90th : Typical cost for annual check-up prophylaxis includes comprehensive oral exam and intraoral complete series of x-ray ALL RIGHTS RESERVED TO UNITED HEALTH PROGRAMS OF AMERICA, DIRECTORY SERVICESA Registered Trademark of United Health Programs of America, Eileen Way, Syosset, NY 11791800-238-3884 Fee Schedule maintaining your family's health should be simple and for programs beginning with 2015 & 2016 start dates and programs with no expiration SAVINGS Note: Typical Cost may vary from one doctor to another.

6 *Provided by ADA DENTAL Survey 2014.** In conjunction with paid annual check-up prophylaxis (cleaning). Prices as of 1/14 and are subject to change without Typical CostDDSAYou SAVEC omplete Series X-ray Films$133 $0**$133 Oral Exam$81 $0**$81 Filling, 1 surface permanent$133 $48 $85 Root Canal, Anterior Tooth$694 $270 $424 Full Denture, upper or lower$1,590 $594 $996 Orthodontics$5,830 $3,338 $2,492 D-001_012810_V01 CODE DDSAT ypicalCost*You SAVEDIAGNOSTIC PROCEDURESD0120 Periodic oral examination0**$53 $53 D0140 Limited Oral Evaluation0**$69 $69 D0150 Comprehensive oral examination0**$81 $81 D0210 (including bitewings) 0** $133 $133 D0220 0**$28 $28 D0230 0**$21 $21 D0270 0**N/AN/AD0272 0**$42 $42 D02740**$81 $81 D0330 0**$106 $106 **I n conjuncti on with paid annual check-up prophylaxis (cleaning), $ for adults and $ fo r children. Children are up to and including 16 years of PROCEDURESD1110 Prophylaxis- adult (additi onal in same membership year)$39 $94 $55 D1120 Prophylaxis-child (additional in same membership year)$28 $71 $43 DD1130 Annual Check-up prophylaxis - Adult$58 $307 $249 DD1140 Annual Check-up prophylaxis - Child$40 $284 $244 D1206 Topical application of fluoride (excluding pr ophylaxis-child)$14 $40 $26 D1208 Topical application of fluoride (excluding prophylaxis-adult)

7 $12 $42 $30 D1351 Sealant - per tooth$18 $53 $35 D1510$118 $318 $200 D1515$172 $423 $251 RESTORATIVE PROCEDURESD2140 Amalgam-1surface, permanent or primary$50 $133 $83 D2150 Amalgam-2 surface, permanent or primary$64 $160 $96 D2160 Amalgam-3 surface, permanent or primary$76 $192 $116 D2161 Amalgam-4 surface, permanent or primary$91 $229 $138 D2330 Resin-1 surface, anterior$61 $159 $98 D2331 Resin-2 surface, anterior$76 $196 $120 D2332 Resin-3 surface, anterior$95 $239 $144 D2335 Resin-4+ surfaces or involving incisal angle$119 $288 $169 D2391 Resin-1 surface, posterior$74 $175 $101 D2392 Resin-2 surface, posterior$101 $228 $127 D2393 Resin-3 surface, posterior$126 $302 $176 D2750 Crown-porcelain fused to high noble metal$534 $971 $437 D2751Cr own-porcelain fused to base metal$473 $901 $428 D2752Cr own-porcelain fused to noble metal$501 $949 $448 D2791Cr own-full cast (base metal)$428 N/AN/AD2920Re-cement crown$39 $95 $56 D2930 Prefab'd stainless steel crown-1 tooth$111 $255 $144 D2931 Prefab'd stainless steel crown-2 tooth$131 $296 $165 D2932 Prefab'd resin crownProtective Restoration$123 N/AN/AD2940$45 $101 $56 D2950 Core buildup, including any pins$111 $253 $142 D2951 Pin retention-per tooth, in add.

8 To restoration$27 N/AN/AD2952 Cast post and core, in addition to crown$167 $371 $204 D2953 Cast post (each additional cast post as part of tooth)$134 N/AN/AD2954 Prefab'd post and core in add. to crown$139 N/AN/AD2960 Labial veneer (resin laminate), chairsi de$323 $636 $313 D2970 Temporary crown (F ractured tooth)$111 N/AN/AD2971 Additional procedures to construct ne w cr own under existing partial denture framewor k$111 N/AN/AGENERAL DENTIST FEESas performed by General PractitionersCODE DDSAT ypicalCost*You SAVEENDODONTIC PROCEDURESD3110 Pulp cap - direct $28 $90 $62 D3120 Pulp cap - indirect $28 $94 $66 D3220 Therapeutic pulpotomy $67 $199 $132 D3310 Root Canal therapy - anterior $284 $694 $410 D3320 Root Canal therapy - bicuspid $342 $806 $464 D3330 Root Canal therapy - molar $428 $969 $541 D3920 Hemisection (incl root removal; excl root canal therap y)$145 N/AN/APERIODONTIC PROCEDURESD4210 Gingivectomy or gi ngivopl as ty, 4+ co nti guous teeth/quad$234 $628 $394 D4211 Gingivectomy or gingivoplasty, 1-3 contiguous teeth/quad$90 $318 $228 D4240 Gper quadrant$312 N/AN/AD4260 quadrant$428 $1,034 $606 D4270 Pedicle soft tiss ue graft procedure$323 N/AN/AD4341 Periodontal scaling and root planing, per quadrant$101 $242 $141 D4345 Periodontal scaling in the presence of gingival $112 N/AN/AD4355 Ful l mouth debridement to enable comprehensive ev aluation and diagnosis$84 N/AN/AD4910 Periodontal maintenance pr ocedures (following active therap y)

9 $61 $140 $79 PROSTHODONTICS, REMOVABLED5110 Complete upper denture, incl 6 months post-insertion care$623 $1,590 $967 D5120 Complete lo wer denture, incl 6 months post-insertion care$623 $1,590 $967 D5130 Immediate upper denture, incl 6 months post-insertion care; does not include required future re basing/relining care; or a complete ne w denture$695 $1,696 $1,001 D5140 Immediate lo wer denture, incl 6 months post-insertion care; does not include required future re basing/relining care; or a complete ne w denture$695 $1,696 $1,001 D5211 Upper partial denture -resin base, including an y conventional clasps and rests$507 $1,346 $839 D5212 Lo wer partial denture - resin base, including an y conventional clasps and rests$507 $1,373 $866 D5213 Upper partial denture - predominantly base cast base with resin base incl an y conventional clasps and rests$657 $1,696 $1,039 D5214 Lower partia l denture-predominantly base cast base with resin base incl any conventional clasps and rests$657 $1,696 $1,039 D5410 Adjust complete denture-upper (after 6 mos)$39 N/AN/AD5411 Adjust complete denture-lower (after 6 mos)$39 N/AN/AD5421 Adjust partial denture-upper (after 6 mos)$39 N/AN/AD5422 Adjust partial denture-lower (after 6 mos)

10 $39 N/AN/AD5510 Repair brok en complete denture base$70 $223 $153 D5520 Replace missing/broken teeth, complete denture-each tooth$58 $180 $122 D5610 Repair partial denture resin saddle or base$78 $212 $134 D5630 Repair or replace partial denture broken clasp$84 N/AN/AD5640 Replace broken teeth - partial denture - per tooth$67 $180 $113 D5650 Add tooth to existing partial denture$83 $210 $127 D5660 Add clasp to existing partial denture$71 $261 $178 D5710 Rebase complete upper denture (LAB)$224 $530 $306 CODE DDSAT ypicalCost*You SAVEPROSTHODONTICS, REMOVABLE continuedD5711 Rebase complete lower denture (LAB)$228 N/AN/AD5720 Rebase partial upper denture (LAB)$228 N/AN/AD5721 Rebase partial lower denture (LAB)$228 N/AN/AD5730 Reline complete upper denture (chairside)$145 $355 $210 D5731 Reline complete lower denture (chairside)$145 $355 $210 D5740 Reline upper partial denture (chairside)$145 N/AN/AD5741 Reline lower partial denture (chairside)$145 N/AN/AD5810 Temporary complete denture (upper)$339 N/AN/AD5811 Temporary complete denture (lo wer)$339 N/AN/AD5820 Temporary partial - stayplate denture (upper)$301 N/AN/AD5821 Temporary partial - stayplate denture (lo wer)$301 N/AN/APROSTHODONTICS, FIXED BRIDGESD6210 Pontic - cast high noble metal$501 $954 $453 D6240 Pontic - porcelain fused to high noble metal$498 $974 $476 D6241 Pontic - porcelain fused to base metal$462 $925 $463 D6545 pr osthesis$228 $795 $567 D6751 Crown (abutment) - porcelain fused to base metal$470 $922 $452 D6790 Crown - full cast hight noble metal$504 $954 $451 D6791 Cr own (abutment)