Crown Dental Plan Fee Schedule

Code Procedure Description Member Cost Member Savings Non-Member Cost 0111 Infection Control (Sterilization Fee) $15 $10 $25 0120 Periodic Oral Exam 1 $30 $22 $52 0140 Limited Oral Exam 1 $45 $43 $88 0145 Oral Evaluation 3 years of age or younger 1 $41 $15 $56 0150 Comprehensive Exam 1 $50 $53 $103 0160 Detailed Oral Evaluation by Periodontal Report $50 $60 $110 0170 Re-Evaluation $35 $23 $58 0180 Comprehensive Periodontal Evaluation $60 $59 $119 0210 X-Ray Complete Series 1 $79 $51 $130 0220 X-Ray First Film $15 $13 $28 0230 X-Ray each additional $10 $15 $25 0240 X-Ray Occlusal Film $10 $39 $49 0250 X-Ray Extra Oral First Film $10 $39 $49 0260 X-Ray Extra Oral each additional Film $10 $28 $38 0270 X-Ray Bitewing Single Film $15 $10 $25 0272 X-Ray Bitewing Two Films $25 $28 $53 0273 X-Ray Bitewing Three Films $31 $37 $68 0274 X-Ray Bitewing Four Films $40 $28 $68 0277 Vertical Bitewings Seven to Eight Films $51 $26 $77 0330 X-Ray Panoramic Film 1 $70 $55 $125 0415 Collection of Microorganisms for Culture $75 $26 $101 0431 Oral Cancer Screening $45 $36 $81 0460 Pulp Vitality Tests $34 $34 $68 0470 Diagnostic Casts $60 $73 $133 0486 Accession of Brush Biopsy Sample $177 $43 $220 0502 Other Oral Pathology Procedures, by Report $181 $69 $250

Preventive Procedures (Cleanings ))) Procedures listed below are to prevent oral diseases.

Code Procedure Description Member Cost Member Savings Non-Member Cost 1110 Adult Cleanings (Prophylaxis) 1 $60 $40 $100 1120 Child Cleanings (Prophylaxis) 1 $54 $18 $72 1206 Topical Fluoride Varnish $28 $24 $52 1208 Topical Fluoride $28 $22 $50 1351 Sealant per Tooth $35 $19 $54

Restorative Procedures (Fillings) Procedures to restore lost tooth structures.

2330 Resin Composite 1 Surface Anterior $125 $103 $228 2331 Resin Composite 2 Surface Anterior $140 $123 $263 2332 Resin Composite 3 Surface Anterior $160 $154 $314 2335 Resin Composite 4 or more Surface Anterior $265 $109 $374 2390 Resin Based Composite Crown $291 $60 $351 2391 Resin Based Composite 1 Surface Posterior $125 $90 $215 2392 Resin Based Composite 2 Surface Posterior $140 $145 $285 2393 Resin Based Composite 3 Surface Posterior $160 $184 $344

______Source: Informal Table above: data adapted from the American Dental Association (ADA), Health Policy Institute, “Dental Fees, Results from the 2018 Survey of Dental Fees.”2 Code Procedure Description Member Cost Member Savings Non-Member Cost 2394 Resin Based Composite 4 or more Surface Posterior $265 $220 $485 2510 Inlay Metal 1 Surface $450 $238 $688 2520 Inlay Metal 2 Surface $540 $202 $742 2530 Inlay Metal 3 or more Surfaces $540 $259 $799 2542 Onlay Metallic 2 Surfaces $625 $213 $838 2543 Onlay Metallic 3 Surfaces $625 $223 $848 2544 Onlay Metallic 4 or more Surfaces $625 $233 $858 2610 Inlay Porcelain 1 Surfaces $675 $175 $850 2620 Inlay Porcelain 2 Surfaces $675 $175 $850 2630 Inlay Porcelain 3 or more Surfaces $675 $150 $825 2642 Onlay Porcelain 2 Surfaces $825 $410 $1235 2643 Onlay Porcelain 3 Surfaces $825 $410 $1235 2644 Onlay Porcelain 4 or more Surfaces $700 $250 $950 2662 Onlay Resin Composite 2 Surfaces $600 $275 $875 2663 Onlay Resin Composite 3 Surfaces $600 $275 $875 2664 Onlay Resin Composite 4 or more Surfaces $600 $275 $875

Crowns & Bridge Procedures

Code Procedure Description Member Cost Member Savings Non-Member Cost 2740 Crown Porcelain/Ceramic Substrate 3 $770 $441 $1211 2750 Crown Porcelain High Noble Metal 3 $759 $430 $1189 2751 Crown Porcelain Base Metal 3 $705 $561 $1266 2752 Crown Porcelain Noble Metal 3 $695 $361 $1056 2790 Full Cast Gold Crown 3 $695 $401 $1096 2791 Crown Full Cast predominantly Base Metal 3 $680 $530 $1210 2792 Crown Full Cast Noble Metal 3 $690 $607 $1297 2910 Recement Inlay 3 $72 $56 $128 2920 Recement Crown 3 $80 $38 $118 2930 Stainless Steel Crown Prefab Primary $245 $205 $450 2931 Stainless Steel Crown Prefab Permanent $230 $240 $470 2932 Prefab Resin Crown $207 $108 $315 2933 Prefab Stainless Steel Crown with Resin Window $240 $98 $338 2940 Sedative Filling $85 $52 $137 2950 Core Buildup /Pins $151 $129 $280 2951 Pin Retention per Tooth $62 $30 $92 2952 Cast Post & Core in Addition/Crown $215 $309 $524 2954 Prefab Post /Core in Addition/Crown $188 $210 $398 2960 Labial (Laminate) Veneer (Chairside) $495 $210 $705 2961 Labial Veneer (Resin) Lab $655 $266 $921 2962 Labial Veneer Porcelain Lab $810 $414 $1224 2970 Temporary Crown $135 $247 $382 2971 Additional Procedures to Construct New Crown $115 $70 $185 2975 Coping $71 $24 $95 2980 Crown Repair $124 $257 $384

Endodontist Procedures (Root Canal Therapy) Dental procedures for disease of the dental pulp.

3110 Pulp Cap Direct (excluding Final) $75 $28 $103 3220 Therapeutic Pulpotomy (excluding Final Crown) $121 $145 $266 3221 Pulpal Therapy (Resorbable Filling) Ant. Primary $150 $135 $285 3310 Root Canal Anterior (excluding Final Crown) $484 $417 $901 3320 Root Canal Bicuspid (excluding Final Crown) $565 $452 $1017 3330 Root Canal Molar (excluding Final Crown) $735 $506 $1241

______Source: Informal Table above: data adapted from the ADA, Health Policy Institute, “2018 Survey of Dental Fees.”4 -2- Code Procedure Description Member Cost Member Savings Non-Member Cost 3346 Root Canal Retreatment Anterior $480 $470 $950 3347 Root Canal Retreatment Bicuspid $525 $440 $965 3348 Root Canal Retreatment Molar $680 $330 $1010 3351 Apexification/Recalcification Initial $190 $234 $424 3410 Apicoectomy/Periodontic Surgery Anterior $404 $365 $769 3421 Apicoectomy/Bicuspid 1 st Root $451 $405 $856 3425 Apicoectomy/Molar 1 st Root $495 $430 $925 3426 Apicoectomy/Periradicular Surgery add’l. Root $225 $131 $356 3430 Retrograde Filling $180 $174 $354 3450 Root Amputation per Tooth $305 $125 $430

Periodontist Procedures (Gum Treatment) Procedures to treat disease of the gingival tissues.

4210 Gingivectomy/Gingivoplasty per Quad $360 $248 $608 4211 Gingivectomy/Gingivoplasty per Tooth $177 $126 $303 4240 Gingival Flap Procedure w/right Planning per Quad $480 $385 $865 4241 Gingival Flap includes Root Plan 1-3 $365 $218 $583 4249 Crown Length–Hard by Report $490 $435 $925 4260 Osseous Surgery w/ Flap Entry Grafts & Closures $680 $265 $945 4263 Bone Replacement Graft First Site in Quadrant $445 $383 $828 4264 Bone Replacement Graft each add’l. site/Quad $305 $342 $647 4265 Biologic Materials to aid in Soft & Osseous Tissues $295 $388 $683 4266 Guided Tissue Regeneration Resorbable Barrier/Site $330 $95 $425 4267 Guided Tissue Regeneration Non-Resorbable Barrier $305 $74 $379 4268 Surgical Revision Procedure, per Tooth $390 $125 $515 4270 Pedicle Tissue Graft $375 $300 $675 4271 Free Soft Tissue Graft & Donor Site $424 $361 $785 4341 Periodontal Scaling Root Planning > 4 Teeth $172 $129 $301 4342 Periodontal RPC (1 to 3 Teeth) $145 $67 $212 4355 Full Mouth Debridement $138 $99 $237 4381 Localized Delivery of Antimicrobial Agents $61 $94 $155 4910 Periodontal Maintenance $91 $52 $143 4920 Unscheduled Dressing Change $71 $25 $96

Prosthodontist (Dentures) Artificial replacements for missing natural teeth. Extra charge for lab fees.

Code Procedure Description Member Cost Member Savings Non-Member Cost 5110 Complete Denture Upper (High Quality) $1175 $1170 $2345 5120 Complete Denture Lower (High Quality) $1175 $2083 $3258 5130 Immediate Dentures Upper (High Quality) $1510 $1748 $3258 5140 Immediate Dentures Lower (High Quality) $1510 $1748 $3258 5211 Upper Partial Denture Resin Base $1110 $567 $1672 5212 Lower Partial Denture Resin Base $1110 $567 $1672 5213 Upper Partial Denture (Cast Metal) $1250 $908 $2158 5214 Lower Partial Denture (Cast Metal) $1250 $915 $2164 5225 Maxillary Partial Denture Flexible Base $1025 $833 $1858 5226 Mandibular Partial Denture Flexible Base $1025 $826 $1851 5281 Removable Unilateral Partial Denture $525 $747 $1272 5410 Adjust Complete Denture Uppers $65 $26 $91 5411 Adjust Complete Denture Lowers $65 $26 $91 5421 Adjust Partial Denture Uppers $70 $26 $96 5422 Adjust Partial Denture Lowers $70 $26 $96 5510 Repair Broken Complete Denture Base $124 $178 $302 5520 Replace Missing/Broken Teeth-Complete Denture $120 $150 $270

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Code Procedure Description Member Cost Member Savings Non-Member Cost 5610 Repair Resin Denture Base $98 $95 $193 5620 Repair Cast Framework $135 $160 $295 5630 Repair/Replace Broken Clasp $145 $290 $435 5640 Replace Broken Teeth per Tooth $95 $185 $280 5650 Add Tooth to Existing Partial Denture $135 $155 $290 5660 Add Clasp to Existing Partial Denture $144 $280 $424 5710 Rebase Complete Upper Denture $340 $364 $704 5711 Rebase Complete Lower Denture $340 $363 $703 5720 Rebase Upper Partial Denture $315 $363 $678 5721 Rebase Lower Partial Denture $315 $363 $678 5730 Reline Complete Upper Denture (Chairside) $197 $481 $582 5731 Reline Complete Lower Denture (Chairside) $197 $455 $652 5740 Reline Upper Partial Denture (Chairside) $255 $397 $652 5741 Reline Lower Partial Denture (Chairside) $255 $397 $652 5750 Reline Complete Upper Denture (Lab) $255 $397 $652 5751 Reline Complete Lower Denture (Lab) $255 $397 $652 5760 Reline Upper Partial Dentures (Lab) $255 $397 $652 5761 Reline Lower Partial Dentures (Lab) $255 $397 $652 5820 Interim Partial Denture Upper $400 $365 $765 5821 Interim Partial Denture Lower $400 $365 $765 5850 Tissue Conditioning Upper $98 $103 $201 5851 Tissue Conditioning Lower $98 $105 $203 5860 Over Denture Complete by Report $890 $420 $1310 5861 Over Denture Partial by Report $890 $420 $1310 5862 Precision Attachment by Report $380 $125 $505

Pontics Procedures (Bridgework) Artificial replacements for missing natural teeth.

Code Procedure Description Member Cost Member Savings Non-Member Cost

6210 Pontic High Noble 3 $687 $537 $1224 6212 Pontic Noble Metal 3 $676 $548 $1224 6240 Pontic Porcelain/High Noble Metal 3 $680 $544 $1224 6241 Pontic Porcelain/Metal 3 $660 $544 $1224 6242 Pontic Porcelain/Noble Metal 3 $682 $574 $1256 6245 Pontic Porcelain/Ceramic 3 $755 $576 $1331 6740 Retainer Crown Porcelain/Ceramic 3 $755 $470 $1225 6750 Retainer Crown Porcelain High Noble Metal 3 $740 $484 $1224 6751 Retainer Crown Porcelain Fused Base Metal 3 $720 $537 $1257 6752 Retainer Crown Porcelain Base Metal 3 $730 $494 $1224 6780 Retainer Crown ¾ Cast High Noble Metal 3 $730 $494 $1224 6790 Crown Full Cast High Noble Metal 3 $680 $544 $1224 6791 Crown Full Cast Base Metal 3 $640 $622 $1262 6792 Crown Full Cast Noble Metal 3 $640 $584 $1224 6930 Recement Fixed Partial Denture $71 $75 $146 6940 Stress Breaker $220 $95 $315 6950 Precision Attachment $305 $155 $460 6970 Cast Post/Core + Fixed Partial Dental Retainer $180 $135 $315 6971 Cast Post/Partial of Bridge Retainer $165 $125 $290 6975 Coping Metal $55 $35 $90 6980 Bridge Repair by Report $121 $149 $270

-4- Extraction Procedures Treatments for non-restorable teeth .

Code Procedure Description Member Cost Member Savings Non-Member Cost 7111 Coronal Remnants Deciduous (Including Soft) $75 $43 $118 7140 Simple Extraction, Erupted or Exposed Tooth $98 $131 $229 7210 Surgical Removal of Tooth $205 $130 $335 7220 Remove Impact Tooth Soft Tissue $255 $121 $376 7230 Remove Impact Tooth Part Bony $325 $147 $472 7240 Remove Impact Tooth Complete Bony $390 $192 $582 7241 Surgical Removal/Tooth w/Complications $305 $157 $462 7250 Surgical Removal of Root $190 $100 $290 7260 Oroantral Fistula Closure $850 $191 $1041 7261 Primary Closure of Sinus Perforation $191 $79 $270 7270 Tooth Re-Implantations/Stabilization $314 $195 $509 7280 Surgical Access of Unerupted Tooth $280 $215 $495 7285 Biopsy Oral Tissue Hard $254 $150 $404 7286 Biopsy Oral Tissue Soft $225 $490 $715 7287 Exfoliative Cytological Sample Collection $180 $64 $244 7290 Tooth Repositioned Surgical $194 $180 $374 7310 Ridge Prep Conjunction w/Exits $168 $95 $263 7320 Ridge Prep Not w/Exits $288 $185 $473 7471 Removal of Exostosis per Site $490 $87 $677 7473 Removal of Torus Mandibularis $360 $106 $466 7510 Incision/Drainage of Abscess Intraoral Soft Tissue $188 $62 $250 7511 Incision/Drainage of Abscess Complicated $240 $80 $320 7520 Incision and Drainage of Abscess Extraoral $312 $90 $402 7970 Excision of Hyperplastic Tissue per Arch $278 $112 $390 7971 Removal of Torus Mandibularis $244 $96 $340

Emergency Treatments

Code Procedure Description Member Cost Member Savings Non-Member Cost 9110 Palliative (Emergency) During Hours $75 $83 $158 9440 Palliative (Emergency) After Hours $150 $75 $225

Notes

1. Crown Dental Plan. “Crown Dental Plan Fee Schedule.” (Arizona: Crown Dental Plan, 2020), 1-7. Provider procedures and discount benefits: Dental Provider performs Specialist procedures: Preventative, Restorative, Crowns & Bridges, Endodontist, Periodontist, Pontics, Extraction; Crown Dental Plan Membership discount is twenty percent (20%). Provider Specialist Usual Customary Rate (UCR) discount is twenty percent (20%). Unlisted procedure UCR discount is twenty percent (20%).

2. American Dental Association (ADA), Health Policy Institute. “Dental Fees, Results from the 2018 Survey of Dental Fees.” 2018. https://ebusiness.ada.org/productcatalog/55492/Center-for-Professional-Success/Survey-of-Dental-Fees-2018/CPS-PR063. The ADA website states: “The American Dental Association’s (ADA) survey of fees charged by general practitioners and specialists is gathered from a nationwide random sample of dentists who were asked to record the fee most often charged for each of 269 different dental procedures. Continuing, “the 2018 Survey of Dental Fees sample was selected from the ADA’s national sampling frame of active private practitioners, which includes member and non-member dentists. The survey, representing 11.2% of the population, was a simple random probability sample of 15,000 dentists in private practice, of whom approximately 60% were general practitioners and 40% were specialists.” Crown Dental Plan Fee Schedule: Code, Procedure, Non-Member Cost category; data adapted from the “2018 Survey of Dental Fees.”

3. Crown Dental Plan. “Crown Dental Plan Fee Schedule.” (Arizona: Crown Dental Plan, 2020), 1-7. Lab Fee charges are at the discretion of Dental Provider. Gold and High Noble Metal require additional fee.

4. ADA and Health Policy Institute. “2018 Survey of Dental Fees.” https://ebusiness.ada.org/productcatalog/55492/Center-for- Professional-Success/Survey-of-Dental-Fees-2018/CPS-PR063. In regard to the “2018 Survey of Dental Fees,” The ADA website shares specific survey information: national average fees broken down for both general practitioners and each of the six specialties, national level statistics for fees for more than 200 commonly performed dental procedures, average fees charged by general practitioners broken down into nine regional areas based on U.S. Census divisions, standard deviation and percentiles for each fee. Crown Dental Plan Fee Schedule for Non-Member Cost category represents the Usual Customary Rate (UCR) or “average fee” dental Provider typically charges for dental procedures without Crown Dental Plan Membership. The Usual Customary Rate price averages do vary by geographic region, zip code, dental procedure, and Dental Provider. Crown Dental Plan Members must understand Provider recommended procedure (s), specific Membership discount per procedure, and aggregate cost due before Provider services rendered. -5-

Membership Benefits

• Annual Memberships are often one-third of the cost of • Annual Membership includes unlimited discount traditional dental insurance benefits

• Members save up to sixty percent (60%) off • Change Provider Dentist retain all Membership benefits Usual Customary Rate (UCR)

• Members save up to twenty percent (20%) off • Easily identify cost per procedure and compare Membership Specialist UCR savings to UCR/ Non-Member fees

• Pre-existing conditions are covered • Crown Membership reduces overall dental cost through CareCredit®” finance option offered at enrolled Provider offices

• Annual Membership fee is typically recovered after only • Membership means no deductibles, co-pays, or waiting periods one office visit

Membership Costs

• Annual Single Membership $99.95 • Annual Membership renewal fee due at Membership effective Date • Annual Two Person Membership $139.95 • Member pays procedure fee to Provider same day service • Annual Family Membership $179.95 rendered

• Group Plan cost varies by group and geographic • Non-Member cost or Usual Customary Rate (UCR) represents Region;. contact Crown Dental Plan for a complimentary the average cost patient would expect to pay for Dentist or assessment on how best to provide dental health Specialist procedure without Crown Dental Plan Membership care coverage for your business or association

Membership Enrollment

• Enroll or Renew Membership at • Annual fee is non-refundable after Membership card is mailed www.crowndentalplan.com, choose Enroll/Renew and follow online steps to complete Membership enrollment

• Method of payment: pay online by credit card, or print • Mailing address: Crown Dental Plan, 1237 S. Val Vista Drive, enrollment form online and mail, or fax, or Enroll/Renew Mesa, AZ 85295 by telephone

• Acceptable forms of payment are credit card, personal • Crown Dental Plan Telephone (480) 964-7449 check or cashier's check

• After enrollment and payment are processed Membership • Crown Dental Plan Fax (480) 627-0557 card arrives within three to five business days

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Eligible Dependents

• All dependents under the age of 19 years old or • Eligible dependents are required to reside in the same full-time students up to age 26 years old are covered household

• Family members incapable of self-sustaining • Once Membership card is issued, Dependents may not be employment by reason of developmental disability added to Crown Dental Plan or physical handicap are covered

Exclusions/Limitations

•The Crown Dental Plan Fee Schedule cost per procedure is subject to change without notice • If Primary General Dentist office closes, Member can select • Services for injuries covered by Workers’ Compensation A new In-Network Provider and dentist may require Member to complete a dental evaluation which • Services covered by other Medical/Dental insurance plans may include additional office visit and x-ray fees

• Oral surgery requiring the setting of fractures or • The discount is (20%) when Provider Dentist performs dislocation Specialist service

• Treatment of malignancies, cysts, or congenital defects

Appointments

• Appointments accepted after the effective • When dental services are required immediately date of coverage located on Membership card Crown Dental Plan verifies coverage with Provider Dentist on the day of enrollment

• To determine an effective oral treatment plan • Primary Dental Provider may be reassigned to Member's Dental Provider may need to perform a complete proximal home or office location, or by Member choice diagnostic evaluation if Provider decides not to continue with Crown Dental Plan

• Without 24-hour cancellation, Member is charged $50 fee • Dentist and Specialist office policies and procedures are for missed Provider appointment subject to change without notice

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