Schedule of Benefits

GCERT2010-DHMO-SOB sob Page 1 of 22 MET245_SOB_CA (01/25) Fs/f Schedule of Benefits Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* MET245 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and Your Dependent’s costs may include Co-Payments for a Covered Service. *Care under this plan is provided through a network of Selected General Dentists. Your Selected General Dentist is responsible for determining when the services of a Specialty Care Dentist are needed, and facilitating any necessary referral. You and Your Dependents will be advised of the name, address and telephone number of the Specialty Care Dentist in Your or Your Dependent’s Service Area. Missed Appointments: If You or Your Dependents need to cancel or reschedule an appointment, please notify the Selected General Dental Office as far in advance as possible. This will allow the Selected General Dental Office to accommodate another person in need of attention. If You or Your Dependents fail to do this in a timely fashion, You or Your Dependents may be charged a missed appointment fee. Service Your and Your Dependent's Co-Payment • Office visit - per visit (including all fees for sterilization and/or infection control) $5 Code Service Your and Your Dependent's Co-Payment Diagnostic Treatment D0120 Periodic oral evaluation - established patient. An evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. The findings are discussed with the patient. Report additional diagnostic procedures separately. $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 D0150 Comprehensive oral evaluation - new or established patient $0 D0160 Detailed and extensive oral evaluation - problem focused, by report $0 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $0 D0171 Re-evaluation – post-operative office visit $0 D0180 Comprehensive periodontal evaluation - new or established patient. This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history, and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, and occlusal relationships. $0 D0190 Screening of a patient $0 D0191 Assessment of a patient $0 Radiographs / Diagnostic Imaging (X-rays) D0210 A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all. $0 D0220 Intraoral – periapical first radiographic image $0

Page 2 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D0230 Intraoral – periapical each additional radiographic image $0 D0240 Intraoral – occlusal radiographic image $0 D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector $0 D0251 Extra-oral posterior dental radiographic image $0 D0270 Bitewing – single radiographic image $0 D0272 Bitewings – two radiographic images $0 D0273 Bitewings – three radiographic images $0 D0274 Bitewings – four radiographic images $0 D0277 Vertical bitewings – 7 to 8 radiographic images $0 D0330 Panoramic radiographic image $0 D0340 2D cephalometric radiographic image – acquisition, measurement and analysis $0 D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $0 D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw $180 D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible $180 D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium $180 D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium $180 D0372 A radiographic survey of the whole mouth intended to display the crowns and roots of all teeth, periapical areas, interproximal areas and alveolar bone including edentulous areas. Comprehensive series of radiographic images. $0 D0373 Intraoral tomosynthesis- bitewing radiographic image $0 D0374 Intraoral tomosynthesis – periapical radiographic image $0 D0380 Cone beam CT image capture with limited field of view – less than one whole jaw $180 D0381 Cone beam CT image capture with field of view of one full dental arch – mandible $180 D0382 Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium $180 D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium $180 D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report $0 D0396 3D printing of a 3D dental surface scan $0 Tests and Examinations D0415 Collection of microorganisms for culture and sensitivity $0 D0425 Caries susceptibility tests $0 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $50

Page 3 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 D0472 Accession of tissue, gross examination, preparation and transmission of written report $0 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $0 D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $0 D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report $0 D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report $0 D0502 Other oral pathology procedures, by report $0 Preventive Services D1110 Removal of plaque, calculus and stains from the tooth structures and implants in the permanent and transitional dentition. It is intended to control local irritational factors. $0 • Additional-adult prophylaxis (maximum of 2 additional per year) $35 D1120 Removal of plaque, calculus and stains from the tooth structures and implants in the primary and transitional dentition. It is intended to control local irritational factors. $0 • Additional-child prophylaxis (maximum of 2 additional per year) $25 D1206 Topical application of fluoride varnish $0 D1208 Topical application of fluoride – excluding varnish $0 D1310 Nutritional counseling for control of dental disease $0 D1320 Tobacco counseling for the control and prevention of oral disease $0 D1330 Oral hygiene instructions $0 • Includes periodontal hygiene instruction D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1353 Sealant repair - per tooth $0 D1354 Application of caries arresting medicament – per tooth. Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. $0 D1355 Caries preventive medicament application – per tooth $0 D1510 Space maintainer – fixed, unilateral – per quadrant Excludes a distal shoe space maintainer $25 D1516 Space maintainer – fixed – bilateral, maxillary $25 D1517 Space maintainer – fixed – bilateral, mandibular $25 D1520 Space maintainer – removable, unilateral – per quadrant $35 D1526 Space maintainer – removable – bilateral, maxillary $35 D1527 Space maintainer – removable – bilateral, mandibular $35

Page 4 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D1551 Re-cement or re-bond bilateral space maintainer – maxillary $15 D1552 Re-cement or re-bond bilateral space maintainer – mandibular $15 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $15 D1556 Removal of fixed unilateral space maintainer – per quadrant $15 D1557 Removal of fixed bilateral space maintainer – maxillary $15 D1558 Removal of fixed bilateral space maintainer – mandibular $15 D1575 Distal shoe space maintainer – fixed, unilateral – per quadrant Fabrication and delivery of fixed appliance extending subgingivally and distally to guide the eruption of the first permanent molar. Does not include ongoing follow-up or adjustments, or replacement appliance, once the tooth had erupted $25 Restorative Treatment D2140 Amalgam – one surface, primary or permanent $0 D2150 Amalgam – two surfaces, primary or permanent $0 D2160 Amalgam – three surfaces, primary or permanent $0 D2161 Amalgam – four or more surfaces, primary or permanent $0 D2330 Resin-based composite – one surface, anterior $0 D2331 Resin-based composite – two surfaces, anterior $0 D2332 Resin-based composite – three surfaces, anterior $0 D2335 Resin-based composite – four or more surfaces (anterior) $0 D2390 Resin-based composite crown, anterior $30 D2391 Resin-based composite – one surface, posterior $30 D2392 Resin-based composite – two surfaces, posterior $45 D2393 Resin-based composite – three surfaces, posterior $65 D2394 Resin-based composite – four or more surfaces, posterior $65 Crowns • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D2510 Inlay – metallic – one surface $225 D2520 Inlay – metallic – two surfaces $235 D2530 Inlay – metallic – three or more surfaces $245 D2542 Onlay – metallic – two surfaces $245 D2543 Onlay – metallic – three surfaces $260 D2544 Onlay – metallic – four or more surfaces $270 D2610 Inlay – porcelain/ceramic – one surface $245 D2620 Inlay – porcelain/ceramic – two surfaces $245 D2630 Inlay – porcelain/ceramic – three or more surfaces $245 D2642 Onlay – porcelain/ceramic – two surfaces $245 D2643 Onlay – porcelain/ceramic – three surfaces $245 D2644 Onlay – porcelain/ceramic – four or more surfaces $245 D2650 Inlay – resin-based composite – one surface $245 D2651 Inlay – resin-based composite – two surfaces $245 D2652 Inlay – resin-based composite – three or more surfaces $245 D2662 Onlay – resin-based composite – two surfaces $245

Page 5 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D2663 Onlay – resin-based composite – three surfaces $245 D2664 Onlay – resin-based composite – four or more surfaces $245 D2710 Crown – resin-based composite (indirect) $245 D2712 Crown – ¾ resin-based composite (indirect) $245 D2720 Crown – resin with high noble metal $245 D2721 Crown – resin with predominantly base metal $245 D2722 Crown – resin with noble metal $245 D2740 Crown – porcelain/ceramic $245 D2750 Crown – porcelain fused to high noble metal $245 D2751 Crown – porcelain fused to predominantly base metal $245 D2752 Crown – porcelain fused to noble metal $245 D2753 Crown – porcelain fused to titanium and titanium alloys $245 D2780 Crown – ¾ cast high noble metal $245 D2781 Crown – ¾ cast predominantly base metal $245 D2782 Crown – ¾ cast noble metal $245 D2783 Crown – ¾ porcelain/ceramic $245 D2790 Crown – full cast high noble metal $245 D2791 Crown – full cast predominantly base metal $245 D2792 Crown – full cast noble metal $245 D2794 Crown – titanium and titanium alloys $245 D2799 Interim crown – further treatment or completion of diagnosis necessary prior to final impression. Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary crown for a routine prosthetic restoration. $70 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $0 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $0 D2920 Re-cement or re-bond crown $0 D2928 Prefabricated porcelain/ceramic crown – permanent tooth $123 D2930 Prefabricated stainless steel crown – primary tooth $25 D2931 Prefabricated stainless steel crown – permanent tooth $25 D2932 Prefabricated resin crown $45 D2933 Prefabricated stainless steel crown with resin window $45 D2940 Placement of interim direct restoration Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, manage caries, create a seal for endodontic isolation, or prevent further deterioration until definitive treatment can be rendered. Not to be used for endodontic access closure, or as a base or liner under restoration. $0 D2950 Core buildup, including any pins when required $70 D2951 Pin retention – per tooth, in addition to restoration $10 D2952 Post and core in addition to crown, indirectly fabricated $50 D2953 Each additional indirectly fabricated post – same tooth $50 D2954 Prefabricated post and core in addition to crown $30 D2955 Post removal $10 D2957 Each additional prefabricated post – same tooth $30 D2960 Labial veneer (resin laminate) – chairside $250

Page 6 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D2961 Labial veneer (resin laminate) – laboratory $300 D2962 Labial veneer (porcelain laminate) – laboratory $350 D2970 Temporary crown (fractured tooth) $0 D2971 Additional procedures to customize a crown to fit under an existing partial denture framework. This procedure is in addition to the separate a crown procedure documented with its own code. $50 D2976 Band stabilization – per tooth $7 D2980 Crown repair necessitated by restorative material failure $0 D2981 Inlay repair necessitated by restorative material failure $0 D2982 Onlay repair necessitated by restorative material failure $0 D2983 Veneer repair necessitated by restorative material failure $0 D2989 Excavation of a tooth resulting in the determination of non-restorability $0 D2990 Resin infiltration of incipient smooth surface lesions $0 Endodontics • All procedures exclude final restoration. D3110 Pulp cap – direct (excluding final restoration) $5 D3120 Pulp cap – indirect (excluding final restoration) $5 D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament $30 D3221 Pulpal debridement, primary and permanent teeth $55 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $30 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $40 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $40 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $100 D3320 Endodontic therapy, premolar tooth (excluding final restoration) $152 D3330 Endodontic therapy, molar tooth (excluding final restoration) $210 D3331 Treatment of root canal obstruction; non-surgical access $85 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $96 D3333 Internal root repair of perforation defects: Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by same provider. $85 D3346 Retreatment of previous root canal therapy – anterior $180 D3347 Retreatment of previous root canal therapy – premolar $280 D3348 Retreatment of previous root canal therapy – molar $325 D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) $70 D3352 Apexification/recalcification – interim medication replacement $70 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $70 D3355 Pulpal regeneration - initial visit $70 D3356 Pulpal regeneration - interim medication replacement $35

Page 7 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D3357 Pulpal regeneration - completion of treatment $70 D3410 Apicoectomy – anterior $95 D3421 Apicoectomy – premolar (first root) $95 D3425 Apicoectomy – molar (first root) $95 D3426 Apicoectomy (each additional root) $60 D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site $180 D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site $95 D3430 Retrograde filling – per root $60 D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery $95 D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery $215 D3450 Root amputation – per root $95 D3460 Endodontic endosseous implant $555 D3471 Surgical repair of root resorption – anterior $72 D3472 Surgical repair of root resorption – premolar $72 D3473 Surgical repair of root resorption – molar $72 D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption – anterior $54 D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption – premolar $54 D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption – molar $54 D3910 Surgical procedure for isolation of tooth with rubber dam $0 D3920 Hemisection (including any root removal), not including root canal therapy $90 D3921 Decoronation or submergence of an erupted tooth $41 D3950 Canal preparation and fitting of preformed dowel or post $15 Periodontics • Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant $110 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant $83 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $25

Page 8 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bound spaces per quadrant: A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased access to the root surface and alveolar bone, or to determine the presence of a cracked tooth or fractured root. Other procedures may be required concurrent to D4240 and should be reported separately using their own unique codes. $150 D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bound spaces per quadrant: A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased access to the root surface and alveolar bone, or to determine the presence of a cracked tooth or fractured root. Other procedures may be required concurrent to D4240 and should be reported separately using their own unique codes. $113 D4245 Apically positioned flap $165 D4249 Clinical crown lengthening – hard tissue $150 D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant $300 D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant $225 D4263 Bone replacement graft – retained natural tooth – first site in quadrant $180 D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant $95 D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site. Biologic materials may be used alone or with other regenerative substrates such as bone and barrier membranes, depending upon their formulation and the presentation of the periodontal defect. This procedure does not include surgical entry and closure, wound debridement, osseous contouring, or the placement of graft materials and/or barrier membranes. Other separate procedures may be required concurrent to D4265 and should be reported using their own unique codes. $95 D4266 Guided tissue regeneration, natural teeth – resorbable barrier, per site: This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure can be used for periodontal defects around natural teeth. $215 D4267 Guided tissue regeneration, natural teeth – non-resorbable barrier, per site: This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure can be used for periodontal defects around natural teeth. $255 D4268 Surgical revision procedure, per tooth $0 D4270 Pedicle soft tissue graft procedure $245 D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft $75

Page 9 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) $100 D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft $380 D4276 Combined connective tissue and pedicle graft, per tooth. Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting procedures are needed to achieve the desired outcome. $75 D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft $245 D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site $123 D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site $38 D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site $190 D4322 Splint - intracoronal; natural teeth or prosthetic crowns $95 D4323 Splint - extracoronal; natural teeth or prosthetic crowns $85 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $50 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $38 D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation $0 D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit. $50 D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth $65 D4910 Periodontal maintenance $40 D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) $0 • Additional periodontal maintenance procedures (beyond 2 per 12 months) $55 Removable Prosthodontics • Delivery of removable and fixed Prosthodontics includes up to 3 adjustments within 6 months of delivery date of service. D5110 Complete denture – maxillary $325 D5120 Complete denture – mandibular $325 D5130 Immediate denture – maxillary $350 D5140 Immediate denture – mandibular $350 D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $400 D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $400 D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $425 D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $425 D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $400

Page 10 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $400 D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $425 D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $425 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) $425 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) $425 D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth) $400 D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth) $400 D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary $300 D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular $300 D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant $150 D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant $150 D5410 Adjust complete denture – maxillary $10 D5411 Adjust complete denture – mandibular $10 D5421 Adjust partial denture – maxillary $10 D5422 Adjust partial denture – mandibular $10 D5511 Repair broken complete denture base, mandibular $35 D5512 Repair broken complete denture base, maxillary $35 D5520 Replace missing or broken teeth – complete denture (each tooth) $35 D5611 Repair resin partial denture base, mandibular $35 D5612 Repair resin partial denture base, maxillary $35 D5621 Repair cast partial framework, mandibular $35 D5622 Repair cast partial framework, maxillary $35 D5630 Repair or replace broken retentive clasping materials – per tooth $35 D5640 Replace broken teeth – per tooth $35 D5650 Add tooth to existing partial denture $35 D5660 Add clasp to existing partial denture – per tooth $35 D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $165 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $165 D5710 Rebase complete maxillary denture $75 D5711 Rebase complete mandibular denture $75 D5720 Rebase maxillary partial denture $75 D5721 Rebase mandibular partial denture $75 D5725 Rebase hybrid prosthesis $75 D5730 Reline complete maxillary denture (chairside) $65 D5731 Reline complete mandibular denture (chairside) $65 D5740 Reline maxillary partial denture (chairside) $65 D5741 Reline mandibular partial denture (chairside) $65 D5750 Reline complete maxillary denture (laboratory) $85 D5751 Reline complete mandibular denture (laboratory) $85

Page 11 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D5760 Reline maxillary partial denture (laboratory) $85 D5761 Reline mandibular partial denture (laboratory) $85 D5765 Soft liner for complete or partial removable denture – indirect $85 D5810 Interim complete denture (maxillary) $230 D5811 Interim complete denture (mandibular) $230 D5820 Interim partial denture (maxillary) $160 D5821 Interim partial denture (mandibular) $170 D5850 Tissue conditioning, maxillary $20 D5851 Tissue conditioning, mandibular $20 D5862 Precision attachment, by report. Each pair of components is one precision attachment. Describe the type of attachment used. $160 D5876 Add metal substructure to acrylic full denture (per arch). Use of metal substructure in removable complete dentures without a framework $82 Implant Services Pre-Surgical Services D6190 Radiographic/surgical implant index, by report $130 Surgical Services D6010 Surgical placement of implant body: endosteal implant $1,005 D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant $770 D6013 Surgical placement of mini implant $1,005 D6040 Surgical placement: eposteal implant $1,860 D6050 Surgical placement: transosteal implant $1,170 D6051 Interim implant abutment placement. A healing cap is not an interim abutment. $123 D6100 Surgical removal of implant body $240 D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure $34 D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure $68 D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure $100 D6104 Bone graft at time of implant placement $100 D6105 Removal of implant body not requiring bone removal nor flap elevation $240 D6106 Guided tissue regeneration – resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $215 D6107 Guided tissue regeneration – non-resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $255

Page 12 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment Implant Supported Prosthetics • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6055 Connecting bar – implant supported or abutment supported $345 D6056 Prefabricated abutment – includes modification and placement $245 D6057 Custom fabricated abutment – includes placement $335 D6058 Abutment supported porcelain/ceramic crown $685 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $660 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $640 D6061 Abutment supported porcelain fused to metal crown (noble metal) $645 D6062 Abutment supported cast metal crown (high noble metal) $655 D6063 Abutment supported cast metal crown (predominantly base metal) $640 D6064 Abutment supported cast metal crown (noble metal) $720 D6065 Implant supported porcelain/ceramic crown $725 D6066 Implant supported crown - porcelain fused to high noble alloys. A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant $700 D6067 Implant supported crown - high noble alloys. A single metal crown restoration that is retained, supported and stabilized by an implant $725 D6068 Abutment supported retainer for porcelain/ceramic FPD $680 D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $680 D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $595 D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $635 D6072 Abutment supported retainer for cast metal FPD (high noble metal) $625 D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) $445 D6074 Abutment supported retainer for cast metal FPD (noble metal) $640 D6075 Implant supported retainer for ceramic FPD $720 D6076 Implant supported retainer for FPD - porcelain fused to high noble alloys. A metal- ceramic retainer for a fixed partial denture that gains retention, support and stability from an implant $700 D6077 Implant supported retainer for metal FPD - high noble alloys. A metal retainer for a fixed partial denture that gains retention, support and stability from an implant $510 D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prosthesis and abutments $55 D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure $17 D6082 Implant supported crown – porcelain fused to predominantly base alloys $640 D6083 Implant supported crown – porcelain fused to noble alloys $645 D6084 Implant supported crown – porcelain fused to titanium and titanium alloys $650 D6086 Implant supported crown – predominantly base alloys $640 D6087 Implant supported crown – noble alloys $720

Page 13 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6088 Implant supported crown – titanium and titanium alloys $650 D6089 Accessing and retorquing loose implant screw – per screw $0 D6090 Repair implant supported prosthesis, by report $190 D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment $170 D6092 Re-cement or re-bond implant/abutment supported crown $50 D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $70 D6094 Abutment supported crown - titanium and titanium alloys. A single crown restoration that is retained, supported and stabilized by an abutment on an implant $650 D6096 Remove broken implant retaining screw $24 D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys $700 D6098 Implant supported retainer – porcelain fused to predominantly base alloys $595 D6099 Implant supported retainer for FPD – porcelain fused to noble alloys $635 D6110 Implant/abutment supported removable denture for edentulous arch-maxillary $995 D6111 Implant/abutment supported removable denture for edentulous arch-mandibular $995 D6112 Implant/abutment supported removable denture for partially edentulous arch- maxillary $945 D6113 Implant/abutment supported removable denture for partially edentulous arch- mandibular $945 D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary $2,380 D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular $2,380 D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary $1,410 D6117 Implant/abutment supported fixed denture for partially edentulous arch-mandibular $1,410 D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys $520 D6121 Implant supported retainer for metal FPD – predominantly base alloys $445 D6122 Implant supported retainer for metal FPD – noble alloys $640 D6123 Implant supported retainer for metal FPD – titanium and titanium alloys $520 D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments. $55 D6191 Semi-precision abutment – placement $335 D6192 Semi-precision attachment – placement $252 D6193 Replacement of an implant screw $24 D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys. A retainer for a fixed partial denture that gains retention, support and stability from an abutment on an implant $520 D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys $510 D6197 Replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant. $30 Crowns/Fixed Bridges - Per Unit • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6205 Pontic – indirect resin based composite $245

Page 14 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6210 Pontic – cast high noble metal $245 D6211 Pontic – cast predominantly base metal $245 D6212 Pontic – cast noble metal $245 D6214 Pontic – titanium and titanium alloys $245 D6240 Pontic – porcelain fused to high noble metal $245 D6241 Pontic – porcelain fused to predominantly base metal $245 D6242 Pontic – porcelain fused to noble metal $245 D6243 Pontic – porcelain fused to titanium and titanium alloys $245 D6245 Pontic – porcelain/ceramic $265 D6250 Pontic – resin with high noble metal $245 D6251 Pontic – resin with predominantly base metal $245 D6252 Pontic – resin with noble metal $245 D6253 Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary pontic for a routine prosthetic restoration. $70 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis $100 D6549 Resin retainer – for resin bonded fixed prosthesis $75 D6600 Retainer inlay – porcelain/ceramic, two surfaces $245 D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $245 D6602 Retainer inlay – cast high noble metal, two surfaces $245 D6603 Retainer inlay – cast high noble metal, three or more surfaces $245 D6604 Retainer inlay – cast predominantly base metal, two surfaces $245 D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $245 D6606 Retainer inlay – cast noble metal, two surfaces $245 D6607 Retainer inlay – cast noble metal, three or more surfaces $245 D6608 Retainer onlay – porcelain/ceramic, two surfaces $245 D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $245 D6610 Retainer onlay – cast high noble metal, two surfaces $245 D6611 Retainer onlay – cast high noble metal, three or more surfaces $245 D6612 Retainer onlay – cast predominantly base metal, two surfaces $245 D6613 Retainer onlay – cast predominantly base metal, three or more surfaces $245 D6614 Retainer onlay – cast noble metal, two surfaces $245 D6615 Retainer onlay – cast noble metal, three or more surfaces $245 D6624 Retainer inlay – titanium $245 D6634 Retainer onlay – titanium $245 D6710 Retainer crown – indirect resin based composite $245 D6720 Retainer crown – resin with high noble metal $245 D6721 Retainer crown – resin with predominantly base metal $245 D6722 Retainer crown – resin with noble metal $245 D6740 Retainer crown – porcelain/ceramic $245 D6750 Retainer crown – porcelain fused to high noble metal $245 D6751 Retainer crown – porcelain fused to predominantly base metal $245 D6752 Retainer crown – porcelain fused to noble metal $245 D6753 Retainer crown – porcelain fused to titanium and titanium alloys $245 D6780 Retainer crown – ¾ cast high noble metal $245

Page 15 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6781 Retainer crown – ¾ cast predominantly base metal $245 D6782 Retainer crown – ¾ cast noble metal $245 D6783 Retainer crown – ¾ porcelain/ceramic $245 D6784 Retainer crown – ¾ titanium and titanium alloys $245 D6790 Retainer crown – full cast high noble metal $245 D6791 Retainer crown – full cast predominantly base metal $245 D6792 Retainer crown – full cast noble metal $245 D6793 Interim pontic. Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary retainer crown for a routine prosthetic restoration. $70 D6794 Retainer crown – titanium and titanium alloys $245 D6930 Re-cement or re-bond fixed partial denture $0 D6940 Stress breaker $110 D6950 Precision attachment. A pair of components constitutes one precision attachment, that is separate from the prosthesis. $195 D6980 Fixed partial denture repair necessitated by restorative material failure $45 Oral Surgery • Includes routine post operative visits/treatment. • The removal of asymptomatic third molars is not a Covered Service unless pathology (disease) exists. D7111 Extraction, coronal remnants – primary tooth $5 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $5 D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $30 D7220 Removal of impacted tooth – soft tissue $50 D7230 Removal of impacted tooth – partially bony $65 D7240 Removal of impacted tooth – completely bony $80 D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $100 D7250 Removal of residual tooth roots (cutting procedure) $40 D7251 Coronectomy – intentional partial tooth removal, impacted teeth only: Intentional partial tooth removal is performed when a neurovascular complication is likely if the entire tooth is removed. $80 D7252 Partial extraction for immediate implant placement Sectioning the root of a tooth vertically, then extracting the palatal portion of the root. The buccal section of the root is retained in order to stablize the buccal plate prior to immediate implant placement. Also known as the Socket Shield Technique. $60 D7260 Oroantral fistula closure $270 D7261 Primary closure of a sinus perforation $275 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $50 D7280 Exposure of an unerupted tooth $100 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $90 D7283 Placement of an attachment on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280. $90 D7285 Incisional biopsy of oral tissue – hard (bone, tooth) $150 D7286 Incisional biopsy of oral tissue – soft $60 D7287 Exfoliative cytological sample collection $50

Page 16 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D7288 Brush biopsy – transepithelial sample collection $50 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $40 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $40 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $15 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $60 D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $25 D7340 Vestibuloplasty – ridge extension (secondary epithelialization) $370 D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $990 D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm $130 D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm $335 D7471 Removal of lateral exostosis (maxilla or mandible) $80 D7472 Removal of torus palatinus $60 D7473 Removal of torus mandibularis $60 D7485 Reduction of osseous tuberosity $60 D7510 Incision and drainage of abscess – intraoral soft tissue $35 D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7520 Incision and drainage of abscess – extraoral soft tissue $35 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $125 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $505 D7910 Suture of recent small wounds up to 5 cm $25 D7921 Collection and application of autologous blood concentrate product $95 D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous or nonautogenous, by report $600 D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach $825 D7952 Sinus augmentation via a vertical approach $825 D7953 Bone replacement graft for ridge preservation – per site $100 D7961 Buccal / labial frenectomy (frenulectomy) $50 D7962 lingual frenectomy (frenulectomy) $50 D7963 Frenuloplasty $50 D7970 Excision of hyperplastic tissue – per arch $55 D7971 Excision of pericoronal gingiva $40

Page 17 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D7972 Surgical reduction of fibrous tuberosity $125 Orthodontics • Benefits cover twenty-four (24) months of usual & customary Orthodontic treatment and an additional twenty four (24) months of retention. • Comprehensive Orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $1,000 D8020 Limited orthodontic treatment of the transitional dentition $1,000 D8030 Limited orthodontic treatment of the adolescent dentition $1,000 D8040 Limited orthodontic treatment of the adult dentition $1,000 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,850 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,850 D8090 Comprehensive orthodontic treatment of the adult dentition $1,850 D8091 Comprehensive orthodontic treatment with orthognatic surgery Treatment of cranofacial syndromes or orthopedic discrepancies that require multiple phases of orthodontic treatment including monitoring growth and development between active phases of treatment $1,850 D8660 Pre-orthodontic treatment examination to monitor growth and development $35 D8670 Periodic orthodontic treatment visit $35 D8671 Periodic orthodontic treatment associated with orthognatic surgery $35 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $300 D8681 Removable orthodontic retainer adjustment $0 D8698 Re-cement or re-bond fixed retainer – maxillary $0 D8699 Re-cement or re-bond fixed retainer – mandibular $0 D8701 Repair of fixed retainer, includes reattachment – maxillary $0 D8702 Repair of fixed retainer, includes reattachment – mandibular $0 • • There is a Co-Payment of $250 for Orthodontic treatment planning and records (pre/post x-rays (cephalometric, panoramic, etc.), photos, study models). There is a Co-Payment of $25 per visit for Orthodontic visits beyond twenty-four (24) months of active treatment or retention. Adjunctive General Services D9110 Palliative treatment of dental pain per visit: Treatment that relieves pain but is not curative; services provided do not have distinct procedure codes. This is typically reported on a “per-visit” basis for emergency treatment of dental pain. $10 D9120 Fixed partial denture sectioning $0 D9210 Local anesthesia not in conjunction with operative or surgical procedures $0 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9215 Local anesthesia in conjunction with operative or surgical procedures $0 D9219 Evaluation for moderate sedation, deep sedation or general anesthesia $0 D9222 Deep sedation/general anesthesia – first 15 minutes $60 D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment $60 D9230 Inhalation of nitrous oxide/analgesia, anxiolysis $15 D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes $60 D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment $60 D9248 Non-intravenous conscious sedation $15

Page 18 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician $0 D9311 Consultation with a medical health care professional $0 D9430 Office visit for observation (during regularly scheduled hours) – no other services performed $0 D9440 Office visit – after regularly scheduled hours $30 D9450 Case presentation, subsequent to detailed and extensive treatment planning. $0 D9610 Therapeutic parenteral drug, single administration $15 D9612 Therapeutic parenteral drugs, two or more administrations, different medications $25 D9613 Infiltration of sustained release therapeutic drug, per quadrant. Infiltration of a sustained release pharmacologic agent for long acting surgical site pain control. Not for local anesthesia purposes. $15 D9630 Drugs or medicaments dispensed in the office for home use $15 D9910 Application of desensitizing medicament $15 D9930 Treatment of complication (post-surgical) – unusual circumstances, by report $0 D9932 Cleaning and inspection of removable complete denture, maxillary $55 D9933 Cleaning and inspection of removable complete denture, mandibular $55 D9934 Cleaning and inspection of removable partial denture, maxillary $55 D9935 Cleaning and inspection of removable partial denture, mandibular $55 D9942 Repair and/or reline of occlusal guard $40 D9943 Occlusal guard adjustment $10 D9944 Occlusal guard – hard appliance, full arch $85 D9945 Occlusal guard – soft appliance, full arch $85 D9946 Occlusal guard – hard appliance, partial arch $64 D9951 Occlusal adjustment – limited $30 D9952 Occlusal adjustment – complete $100 D9954 Fabrications and delivery of oral appliance therapy (OAT) morning repositioning device $16 D9955 Oral appliance therapy (OAT) titration visit $10 D9986 Missed appointment (less than 24-hr notice) Not to exceed $25 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association

Page 19 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB limit Dental benefits: Limitations and additional charges General 1. Specialty Care Dentists will accept the contracted fee for all Covered Services. 2. General anesthesia or IV sedation is a Covered Service only if it is provided in a Selected General Dental Office, administered by the Selected General Dentist or Specialty Care Dentist, and is in conjunction with covered oral and periodontal surgical procedures or when deemed necessary by the Selected General Dentist or Specialty Care Dentist. 3. Sterilization and infection control are not billable to Us or You or Your Dependent and are included within the charges for other services provided on that date of service. a. Local Anesthetic is included in all restorative and surgical procedure fees. b. All adhesives, liners, bases and occlusal adjustments are included as a part of the restorative procedure. Diagnostic 1. Panoramic or full mouth x-rays (including bitewings): once every three (3) years, unless Dentally Necessary for a specific dental problem. 2. All costs for additional periapical and bitewing x-rays provided on the same day that a full mouth x-ray is provided to You or Your Dependent are included in the costs for the full mouth x-ray. Preventive 1. Routine cleanings (oral Prophylaxis), periodontal maintenance services (following active periodontal therapy) and fluoride treatments are limited to twice a year. Two (2) additional cleanings (routine and periodontal) are available at the Co-Payment listed in the SCHEDULE OF BENEFITS. Additional Prophylaxis are available, if Dentally Necessary. 2. Sealants and/or preventive resin restorations: Plan benefit applies to primary and permanent molar teeth, limited to age 19, one (1) per tooth, per thirty-six (36) months, unless Dentally Necessary. 3. Space maintainers are covered to age 14 once per area, per lifetime. Replacement of lost space maintainers are not a Covered Service. Restorative Treatment Crowns, Implants and Fixed Bridges 1. An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. 2. Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. 3. There is a $75 Co-Payment per molar, for the use of porcelain. 4. Prefabricated stainless steel Crowns or prefabricated resin Crowns are limited to no more than one (1) replacement for the same tooth surface within five (5) years. 5. Charges for temporary Crowns/restorations are included within the costs of the permanent Crown/restoration. 6. Provisional Crowns/restorations are to be used for an interim of at least six (6) months duration. Interim Crowns/restorations are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. 7. Replacement of any Cast Restorations with the same or a different type of Cast Restoration are limited to no more than once every five (5) years. 8. Core buildups are limited to no more than once per tooth in a period of five (5) years. 9. Post and cores are limited to no more than once per tooth in a period of five (5) years. 10. Labial veneers are limited to no more than once per tooth in a period of five (5) years. Prosthodontics 1. Relinings and rebasings are limited to one (1) every twelve (12) months. 2. Dentures (full or partial): Replacement only after five (5) years have elapsed following any prior provision of such Dentures under a SafeGuard Plan, unless due to the loss of a natural tooth which cannot be added to the existing partial. Replacements will be a benefit under this Plan only if the existing Denture is unsatisfactory and cannot be made satisfactory as determined by the treating Selected General Dentist or Specialty Care Dentist. 3. Replacement of an immediate full Denture with a permanent full Denture if the immediate full Denture cannot be made permanent and such replacement is done within twelve (12) months of the installation of the immediate full Denture. 4. Adjustments of Dentures if at least six (6) months have passed since the installation of the existing removable Denture. 5. Delivery of removable and fixed Prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 6. Tissue conditioning eligible one (1) per appliance each twenty-four (24) months.

Page 20 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB limit 7. Provisional prostheses are to be used for an interim of at least six (6) months duration. Interim prostheses are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. Implant Services 1. Implants are limited to no more than once for the same tooth position in a five (5) year period. 2. Repairs of implants are limited to not more than once in a twelve (12) month period. 3. Implant supported prosthetics are limited to no more than once for the same tooth position in a five (5) year period: • when needed to replace congenitally missing teeth; or • when needed to replace natural teeth. 4. The following are limited to no more than two (2) each per year: Implants, Implant supported prosthetics, and Implant abutments. Endodontics 1. The Co-Payments listed for Endodontic procedures do not include the cost of the final restoration. 2. Materials used for canal irrigation are included in the Endodontic procedure fees. Oral Surgery 1. The removal of asymptomatic third molars is not a Covered Service. Pathology (disease) must exist for it to be covered by the program. 2. Includes routine post operative visits/treatments. Periodontics 1. Irrigation (such as Chlorhexidine), is included with the other services rendered that day. 2. Local chemotherapeutic agents are limited to no more than six (6) teeth per arch. Treatment plans involving more than six (6) teeth per arch, require prior Plan approval. 3. Periodontal maintenance is eligible following active periodontal therapy, which includes scaling and root planing, surgery, etc. 4. Periodontal scaling and root planing, is limited to not more than once per Quadrant in any twenty-four (24) month period. 5. Periodontal surgery, including gingivectomy, gingivoplasty and osseous surgery, is limited to no more than one surgical procedure per Quadrant in any thirty-six (36) month period. 6. Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. Orthodontics 1. If You or Your Dependent require the services of an orthodontist, a referral must first be facilitated by Your Selected General Dentist. If a referral is not obtained before the Orthodontic treatment begins, You will be responsible for all costs associated with any Orthodontic treatment. 2. If You or Your Dependent terminate coverage from the SafeGuard Plan after the start of Orthodontic treatment, You will be responsible for any additional charges incurred for the remaining Orthodontic treatment. 3. Orthodontic treatment must be provided by a Selected General Dentist or Specialty Care Dentist whose specialty is orthodontics or pediatric dentistry for the Co-Payments listed in this SCHEDULE OF BENEFITS to apply. 4. Plan benefits shall cover twenty-four (24) months of usual and customary Orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a charge of $25 per visit. 5. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. 6. If You or Your Dependent started orthodontic treatment before Your coverage for Yourself or that Dependent started under this group contract, Continuing Orthodontic treatment is available under this group contract for You or Your Dependent under any of the following circumstances: a. You were covered under the terms of a dental plan provided by SafeGuard and, due to an acquisition, are now covered under the terms of this group contract; b. You were covered under the terms of a dental plan provided by a carrier other than SafeGuard and are now covered under the terms of this group contract because the Contractholder subsequently contracts with SafeGuard; c. You become eligible for DHMO benefits under the terms of this group contract because of Your status as a new employee; or d. You were covered under the terms of a dental plan and received orthodontic services which were not covered because that dental plan did not offer orthodontic coverage. Upon receipt of a completed Continuing Orthodontic Form by Us, with all supporting documentation, We will accept liability for continuing payment of the remaining balance owed, up to a maximum of $1,500 times the percentage of the total treatment remaining as of this group contract’s Effective Date, subject to the section titled DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES and DENTAL BENEFITS: EXCLUSIONS. Continuing Orthodontic treatment will be available if You enroll within 30 days of the date You become eligible for benefits under the terms of this group contract.

Page 21 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB exclusions Dental benefits: Exclusions 1. Any procedures not specifically listed as a Covered Service in this SCHEDULE OF BENEFITS or dental procedures or services performed solely for Cosmetic purposes (unless specifically listed as a Covered Service in this SCHEDULE OF BENEFITS), are not covered. 2. Covered Services must be performed by Your Selected General Dental Office or a SafeGuard Specialty Care Dentist to whom You are referred in accordance with the terms of Your evidence of coverage and SCHEDULE OF BENEFITS. Services performed by any Dentist not contracted with SafeGuard are not Covered Services, without prior approval by SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evidence of coverage and SCHEDULE OF BENEFITS (except for out-of-area emergency services). 3. Dental procedures started prior to Your or Your Dependent's eligibility under this SCHEDULE OF BENEFITS or started after Your or Your Dependent's benefits have ended. For example, teeth prepared for Crowns, root canals in progress (the tooth has been opened into the pulp (nerve chamber)), or full or partial Dentures for which an impression has been taken. 4. Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving You or Your Dependent's dental health, as determined by the Selected General Dentist, and Us based on generally accepted dental standards of care. 5. Orthognathic surgery. 6. Inpatient/outpatient hospital charges of any kind, including prescriptions or medications. General anesthesia or IV sedation is not covered for any reason if rendered in an out patient facility or hospital. Dental charges will be covered, if the procedure performed is covered by the Plan. 7. Replacement of Dentures, Crowns, appliances or Bridgework that have been lost, stolen or damaged. 8. Treatment of malignancies, cysts, or neoplasms, unless specifically listed as a Covered Service in the SCHEDULE OF BENEFITS. Any services related to pathology laboratory fees. 9. Procedures, appliances, or restorations whose primary purpose is to change the vertical dimension of occlusion, correct congenital malformation, developmental, or medically induced dental disorders including, but not limited to, treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specifically listed as a Covered Service in this SCHEDULE OF BENEFITS. 10. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. 11. Dental services required while serving in the armed forces of any country or international authority. 12. Dental services considered Experimental in nature. 13. Treatment required due to an accident from an external force, unless otherwise listed as Covered Service in this SCHEDULE OF BENEFITS. 14. The following are not included as Orthodontic benefits: • Repair or replacement of lost or broken appliances; • Retreatment of Orthodontic cases; • Treatment involving: - Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; - Hormonal imbalances or other factors affecting growth or developmental abnormalities; - Treatment related to temporomandibular joint disorders; • Composite or ceramic brackets, lingual adaptation of Orthodontic bands and other specialized or Cosmetic alternatives to standard fixed and removable Orthodontic appliances. • Invisalign services are excluded.

Page 22 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB Language Assistance As a SafeGuard member you have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains your language preferences, race, and ethnicity so that we can communicate more effectively with our members. If you require language assistance or would like to inform SafeGuard of your preferred language, please contact SafeGuard at (800) 880-1800. Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia en idiomas. Esto incluye servicios de interpretación y traducción. SafeGuard recaba la información sobre sus preferencias de idioma, raza, y etnia de manera que nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia en su idioma o quiere informarle a SafeGuard sobre su idioma de preferencia, comuníquese con SafeGuard al (800) 880-1800.