SPECIALIST SERVICESas performed by Board Eligible or Board Certified dental specialists

CODE DDSA

TypicalCost*

You SAVE

ORAL 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/A N/ASurgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at additional cost to the participating specialist.

PERIODONTIC 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/A N/A

D4260 Osseous surgery-incl flap entry and closure, per quadrant $613 $1,685 $1,072

D4270 Pedicle soft tissue graft procedure $360 N/A N/A

D4341 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/A N/AD3430 Retorgrade filling - per root $139 N/A N/AD3450 Root amputation - per root $178 N/A N/AD3920 Hemisection (incl. root removal; excl. root canal therapy) $200 N/A N/A

CODE DDSA

TypicalCost*

You SAVE

ORTHODONTICS - COMPREHENSIVE CASE, CLASS 1, 11, 111 (up to and including age 16) D8070, D8080Orthodontic records, treatment plan and consultation $112 N/A N/AInitial ortho. appliance, construction and installation $428 N/A N/AActive treatment phase - up to 24 months $2,587 N/A N/ARetention phase per retainer $210 N/A N/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. Invisalign braces are 25% off the usual and customary fee of the participating provider.

DENTAL DIRECTORY SERVICES (DDS), TERMS AND CONDITIONS1. The dental services appearing in this schedule are available from genera

practitioners 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 implantology.

2. Aside from the Annual Check-up, additional exams, x-rays andconsultations are available at a 25% discount at general practitioners.All exams, x-rays and consultations at all specialists are 25% of thedentists usual and customary fee. Invisalign braces are 25% of thedentist usual and customary fees.

3. All participating providers may charge an OSHA sterilization fee pervisit and a lab fee for crown, bridges and denture work.

4. The 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 specialists.

5. Britesmile is not a covered procedure.6. It is the Members responsibility to verify that the dentist is a participating

Provider for DDS before seeking any treatment. Any dental proceduresperformed by a non-participating dentist are not covered.

7. The 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 work.

8. DDS 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 allareas.

9. While 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 RelationsDepartment.

10. Provider listings and/or fee schedules can be updated or changedwithout notice.

*Typical cost provided by ADA Dental Survey 2006, 90th percentile.NOTE: Typical cost for annual check-up prophylaxis includes comprehensive oral exam and intraoral complete series of x-ray films.

2014 ALL RIGHTS RESERVED TO UNITED HEALTH PROGRAMS OF AMERICA, INC.

DENTAL DIRECTORY SERVICESA Registered Trademark of United Health Programs of America, Inc.160 Eileen Way, Syosset, NY 11791800-238-3884

Fee Schedule A

...because maintaining your family's health should be

simple and affordable.

Effective for programs beginning with 2015 & 2016 start dates and programs with no expiration date.

SAMPLE SAVINGS

Note: 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 notice.

PROCEDURES Typical CostDDSA

You SAVE

Complete 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 DDSA

TypicalCost*

You SAVE

DIAGNOSTIC PROCEDURESD0120 Periodic oral examination 0** $53 $53 D0140 Limited Oral Evaluation 0** $69 $69 D0150 Comprehensive oral examination 0** $81 $81

D0210 (including bitewings) 0** $133 $133

D0220 0** $28 $28 D0230 0** $21 $21 D0270 0** N/A N/AD0272 0** $42 $42 D0274 0** $81 $81 D0330 0** $106 $106 **In conjunction with paid annual check-up prophylaxis (cleaning), $58.00 for adults and $40.00 for children. Children are up to and including 16 years of age.

PREVENTATIVE PROCEDURESD1110 Prophylaxis-adult (additional 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 prophylaxis-child) $14 $40 $26

D1208 Topical application of fluoride (excluding prophylaxis-adult) $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 D2751 Crown-porcelain fused to base metal $473 $901 $428 D2752 Crown-porcelain fused to noble metal $501 $949 $448 D2791 Crown-full cast (base metal) $428 N/A N/AD2920 Re-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 crown

Protective Restoration$123 N/A N/A

D2940 $45 $101 $56 D2950 Core buildup, including any pins $111 $253 $142 D2951 Pin retention-per tooth, in add. to restoration $27 N/A N/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/A N/AD2954 Prefab'd post and core in add. to crown $139 N/A N/AD2960 Labial veneer (resin laminate), chairside $323 $636 $313 D2970 Temporary crown (Fractured tooth) $111 N/A N/A

D2971 Additional procedures to construc