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Dental Select HMO (ZE70) Select Another Plan All Office Visits Participating Dental Office Only $5 each visit Participating Specialty Offices n/a Endodontics Root canal: anterior (excluding final restoration) Participating Dental Office Only $289 Participating Specialty Offices $404 Endodontics Root canal: bicuspid (excluding final restoration) Participating Dental Office Only $341 Participating Specialty Offices $460 Endodontics Root canal: molar (excluding final restoration) Participating Dental Office Only $459 Participating Specialty Offices $566 Endodontics Pulpotomy Participating Dental Office Only $62 Participating Specialty Offices $85 Periodontics Gingivectomy: per tooth Participating Dental Office Only $72 Participating Specialty Offices $114 Periodontics Gingivectomy: per quadrant Participating Dental Office Only $194 Participating Specialty Offices $380 Periodontics Scaling/root planing: per quadrant Participating Dental Office Only $101 Participating Specialty Offices $135 Periodontics Osseous surgery: per quadrant Participating Dental Office Only $520 Participating Specialty Offices $735 Oral Surgery Single extraction Participating Dental Office Only $60 Participating Specialty Offices $79 Oral Surgery Impaction: soft tissue Participating Dental Office Only $136 Participating Specialty Offices $161 Diagnostic: Oral examinations Participating Dental Office Only No charge Participating Specialty Offices $30 Oral Surgery Impaction: partial bony Participating Dental Office Only $176 Participating Specialty Offices $197 Oral Surgery Impaction: full bony Participating Dental Office Only $200 Participating Specialty Offices $231 Prosthodontics Crown: porcelain fused to high noble metal Participating Dental Office Only $432 Participating Specialty Offices $486 Prosthodontics Post/core prefabrication Participating Dental Office Only $121 Participating Specialty Offices $164 Prosthodontics Complete denture Participating Dental Office Only $577 Participating Specialty Offices $721 Prosthodontics Partial denture Participating Dental Office Only $430 Participating Specialty Offices $766 Prosthodontics Denture reline: chair side Participating Dental Office Only $103 Participating Specialty Offices $182 Prosthodontics Partial Denture: broken tooth repair Participating Dental Office Only $64 Participating Specialty Offices $95 Other Services Out-of-area emergency care, maximum payment: $50 Participating Dental Office Only All charges over $50 including applicable copay(s) Participating Specialty Offices All charges over $50 including applicable copay(s) Other Services Office visit: after hours Participating Dental Office Only $56 Participating Specialty Offices $56 Diagnostic: X-rays Participating Dental Office Only No charge Participating Specialty Offices Vary by procedure Other Services Local anesthesia Participating Specialty Offices $14 Participating Dental Office Only $14 Orthodontics 24 months of usual and customary orthodontic care, exclusive of records fees Participating Orthodontist Adult (age 18 and over) $3,045; Child (through age 17) $2,870; Retention $210 Preventive Prophylaxis: adult Participating Dental Office Only No charge** Participating Specialty Offices $50 Preventive Prophylaxis: child Participating Dental Office Only No charge** Participating Specialty Offices $44 Preventive Topical Fluoride: child Participating Dental Office Only No charge Participating Specialty Offices $24 Restorative Fillings: amalgams and anterior composites Participating Dental Office Only No charge Participating Specialty Offices Vary by procedure Restorative Stainless steel crowns: primary teeth Participating Dental Office Only $106 Participating Specialty Offices $136 Endodontics Pulp cap: direct Participating Dental Office Only $32 Participating Specialty Offices $47 ** First two treatments in 12 consecutive months. All additional treatments in 12 consecutive months require a copayment

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