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

2 (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.

3 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)

4 $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. 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.

5 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.

6 Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee. 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.

7 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.

8 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.

9 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.

10 Typical Cost may vary from one doctor to another.*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.