Schedule of Dental Allowances - CWA Local 1180

DiagnosticScheduled Dental Benefit PlanSchedule of Dental Allowances0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.000140 Limited Oral Evaluation 20.000150 Comprehensive Oral Evaluation 20.000210 Intraoral – completes series incl. Bitewings (once every 3 years) 30.000220 Intraoral, Periapical, first film 3.500230 Intraoral, Periapical, each additional film 2.000270 Bitewings, single film 3.500272 Bitewings, two films 7.000274 Bitewings, four films 12.000290 Posterior-Anterior/lateral skull and facial bone survey film 27.500321 Other temporomandibular joint films, by report 36.500330 Panoramic film (once every three years) 30.000340 Cephalornetric film 15.00Preventive (once every six months 1110, 1120, 1203, 1204)1110 Prophylaxis – Adult 25.001120 Prophylaxis – Child (to age 12) 20.001203 Topical application of fluoride (prophylaxis not included) – Child 15.001204 Topical application of fluoride (prophylaxis not included) – Adult 15.001351 Sealant – per tooth (once per lifetime) 25.001510 Space Maintainer – Fixed – Unilateral 54.501520 Space Maintainer – Removable – Unilateral 54.50Restorative2140 Amalgam – 1 Surface, Permanent 25.002150 Amalgam – 2 Surfaces, Permanent 35.002160 Amalgam – 3 Surfaces, Permanent 45.002161 Amalgam – 4 or more Surfaces, Permanent 55.002330 Resin – 1 Surface, Anterior 35.002331 Resin – 2 Surfaces, Anterior 45.002332 Resin – 3 Surfaces, Anterior 60.00

2391 Resin – based composite 1 surface, posterior permanent 35.002392 Resin – based composite 2 surfaces, posterior permanent 45.002393 Resin – based composite 3 surfaces, posterior permanent 60.002394 Resin – based composite 4 or more surfaces, posterior permanent 60.002510 Inlay - Metallic - 1 Surface* 100.002520 Inlay - Metallic - 2 Surfaces* 200.002530 Inlay - Metallic - 3 Surfaces* 250.002610 Inlay – Porcelain/Ceramic – 1 Surface* 80.502710 Crown – Resin – base composite (indirect)* 150.002720 Crown – Resin with high noble metal* 175.002721 Crown – Resin with predominantly base metal* 175.002722 Crown – Resin with noble metal* 175.002740 Crown - Porcelain/Ceramic Substrate* 175.002750 Crown – Porcelain fused to high noble metal* 275.002751 Crown – Porcelain fused to predominantly base metal* 275.002752 Crown – Porcelain fused to noble metal* 275.002790 Crown – Full Cast high noble metal* 250.002791 Crown – Full Cast predominantly base metal* 250.002792 Crown – Full Cast noble metal* 250.002910 Recement inlay, only or partial coverage restoration 15.002920 Recement crown 20.002930 Prefabricated stainless steel crown - primary tooth 47.502940 Sedative filling 25.002950 Core build-up 85.002952 Cast post and core in addition to crown 85.002954 Prefabricated post and core in addition to crown 85.002970 Temporary crown 36.502980 Crown repair, by report 30.00*Prosthetics can only be replaced once every five years.

* Maximum of four applications per calendar year.Prosthodontics (removable)5110 Complete upper dentures* 300.005120Complete lower dentures* 300.005130 Immediate upper dentures* 300.005140 Immediate lower dentures* 300.005211 Maxillary partial denture – resin base* 300.005212 Mandibular partial denture – resin base* 300.005213 Maxillary partial denture – cast metal frame/resin base* 300.005214 Mandibular partial denture – cast metal frame/resin base* 300.005281 Removable unilateral partial denture one piececast metal (including clasps & pontics)* 300.005410 Adjust complete denture – maxillary 20.005411 Adjust complete denture – mandibular 20.005421 Adjust partial denture – maxillary 20.005422 Adjust partial denture – mandibular 20.005610 Repair resin denture base 30.005620 Repair cast framework 30.005630 Repair or replace broken clasp 20.005640 Replace broken teeth – per tooth 25.005650 Add tooth to existing partial denture 40.005660 Add clasp to existing partial denture 60.005710 Rebase complete maxillary denture 100.005711 Rebase complete mandibular denture 100.005720 Rebase maxillary partial denture 100.005721 Rebase mandibular partial denture 100.005730 Reline complete upper denture (chairside) 50.005731 Reline complete lower denture (chairside) 50.005740 Reline upper partial denture (chairside) 50.005741 Reline lower partial denture (chairside) 50.005750 Reline complete upper denture (laboratory) 100.005751 Reline complete lower denture (laboratory) 100.00

5760 Reline upper partial denture (laboratory) 100.005761 Reline lower partial denture (laboratory) 100.005862 Precision attachment, by report 50.00Implant Benefit6010 Surgical placement of implant body: endosteal implant **6040 Surgical placement: eposteal implant **6050 Surgical placement: transosteal implant **** 100% up to $1500 paid per procedure/$2000 Lifetime Benefit MaximumImplant Supported Prosthetics6053*, 6054*, 6056*, 6057* 85.006058*, 6059*, 6060*, 6061*, 6062*, 6063*, 6064*, 6065*,6066*, 6067*, 6068*, 6069*, 6070*, 6071*, 6072*, 6073*,6074*, 6075*, 6076*, 6077* 275.00Prosthodontics (fixed6020 Abutment placement or substitution 85.006210 Pontic – cast high noble metal* 100.006211 Pontic – cast predominantly base metal* 100.006212 Pontic – cast noble metal* 100.006240 Pontic – porcelain fused to high noble metal* 225.006241 Pontic – porcelain fused to predominantly base metal* 225.006242 Pontic – porcelain fused to noble metal* 225.006250 Pontic – resin with high noble metal* 125.006251 Pontic – resin with predominantly base metal* 125.006252 Pontic – resin with noble metal* 125.006545 Retainer – cast metal* 250.006720 Crown – resin with high noble metal* 200.00*Prosthetics can only be replaced once every five years.6721 Crown – resin with predominantly base metal* 200.006722 Crown – resin with noble metal* 200.006750 Crown – porcelain fused to high noble metal 275.006751 Crown – porcelain fused to predominantly base metal* 275.00

6752 Crown – porcelain fused to noble metal* 275.006780 Crown – ¾ cast high noble metal* 175.006790 Crown – full cast high noble metal* 275.006791 Crown – full cast predominantly base metal* 250.006792 Crown – full cast noble metal* 250.006930 Recement fixed partial denture 35.006950 Precision attachment 100.006980 Fixed partial denture repair, by report 50.00*Prosthetics can only be replaced once every five years.** 100% up to $1500 paid per procedure/$2000 Lifetime Benefit MaximumOral Surgery (including local anesthesia and post operative care)7111 Extraction, coronal remnants – deciduous tooth 40.007140 Extraction - erupted tooth or exposed root 40.007210 Surgical removal of erupted tooth requiring elevation mucoperiostealflap and removal of bone and/or section of tooth 70.007220 Removal of impacted tooth – soft tissue 125.007230 Removal of impacted tooth – partially bony 150.007240 Removal of impacted tooth – completely bony 200.007241 Removal of impacted tooth – completely bony w/complications 225.007250 Surgical removal of residual roots (cutting procedure) 35.007310 Alveoplasty with extraction – per quadrant 60.007320 Alveoplasty no extractions – per quadrant 50.007440 Excision of malignant tumor – lesion diameter up to 1.25 cm 40.007441 Excision of malignant tumor – lesion diameter over 1.25 cm 40.007510 Incision & drainage of abscess – intraoral soft tissue 25.007520 Incision & drainage of abscess – extraoral soft tissue 20.007960 Frenulectomy 75.00Orthodontics8080 Comprehensive orthodontic treatment of the adolescent dentition(once per lifetime) 500.008090 Comprehensive orthodontic treatment of the adult dentition(once per lifetime) 500.008660 Pre-orthodontic treatment visit (once per lifetime) 150.00

8670 Periodic orthodontic treatment visit as part of contract(up to 24 consecutive months) 60.008680 Orthodontic retention-limit $200 (100 ea. top & bottom) 100.00Adjunctive General Services9110 Palliative (emergency) treatment of dental pain 20.009220 General anesthesia – first 30 minutes 100.009221 General anesthesia – each additional 15 minutes 50.009310 Consultation 30.009951 Occlusal adjustment – limited 20.009952 Occlusal adjustment – complete 50.00