Schedule of Benefits for Direct Referral Dental Plan

Customer Service (800) 880-1800 GCERT2010-DHMO-SOB sob Page 1 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Schedule of Benefits Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* SGX100-CA This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions and Limitations. During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. Missed Appointments: If you need to cancel or reschedule an appointment, you should notify the dental office as far in advance as possible. This will allow the dental office to accommodate another person in need of attention. *Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard for any necessary referral. Code Service 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 • Office visit - per visit (including all fees for sterilization and/or infection control) $5 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 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 D0270 Bitewing – single radiographic image $0 D0272 Bitewings – two radiographic images $0

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 2 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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 D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $0 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 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 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 D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written 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) $20 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) $15 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 D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1510 Space maintainer – fixed, unilateral – per quadrant Excludes a distal shoe space maintainer $0

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 3 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D1516 Space maintainer – fixed – bilateral, maxillary $0 D1517 Space maintainer – fixed – bilateral, mandibular $0 D1520 Space maintainer – removable, unilateral – per quadrant $0 D1526 Space maintainer – removable – bilateral, maxillary $0 D1527 Space maintainer – removable – bilateral, mandibular $0 D1551 Re-cement or re-bond bilateral space maintainer – maxillary $5 D1552 Re-cement or re-bond bilateral space maintainer – mandibular $5 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $5 D1556 Removal of fixed unilateral space maintainer – per quadrant $5 D1557 Removal of fixed bilateral space maintainer – maxillary $5 D1558 Removal of fixed bilateral space maintainer – mandibular $5 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 $0 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 $20 D2391 Resin-based composite – one surface, posterior $25 D2392 Resin-based composite – two surfaces, posterior $30 D2393 Resin-based composite – three surfaces, posterior $35 D2394 Resin-based composite – four or more surfaces, posterior $40 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 crown/bridge unit in addition to regular co-payments for porcelain on molars. • Cases involving seven (7) or more crowns and/or fixed bridge units in the same treatment plan require an additional $125 co-payment per unit in addition to co-payment for each crown/bridge unit. D2510 Inlay – metallic – one surface $100 D2520 Inlay – metallic – two surfaces $100 D2530 Inlay – metallic – three or more surfaces $100 D2542 Onlay – metallic – two surfaces $100 D2543 Onlay – metallic – three surfaces $100 D2544 Onlay – metallic – four or more surfaces $100 D2610 Inlay – porcelain/ceramic – one surface $100 D2620 Inlay – porcelain/ceramic – two surfaces $100 D2630 Inlay – porcelain/ceramic – three or more surfaces $100 D2642 Onlay – porcelain/ceramic – two surfaces $100 D2643 Onlay – porcelain/ceramic – three surfaces $100 D2644 Onlay – porcelain/ceramic – four or more surfaces $100 D2650 Inlay – resin-based composite – one surface $100

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 4 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D2651 Inlay – resin-based composite – two surfaces $100 D2652 Inlay – resin-based composite – three or more surfaces $100 D2662 Onlay – resin-based composite – two surfaces $100 D2663 Onlay – resin-based composite – three surfaces $100 D2664 Onlay – resin-based composite – four or more surfaces $100 D2710 Crown – resin-based composite (indirect) $100 D2712 Crown – ¾ resin-based composite (indirect) $100 D2720 Crown – resin with high noble metal $100 D2721 Crown – resin with predominantly base metal $100 D2722 Crown – resin with noble metal $100 D2740 Crown – porcelain/ceramic $225 D2750 Crown – porcelain fused to high noble metal $100 D2751 Crown – porcelain fused to predominantly base metal $100 D2752 Crown – porcelain fused to noble metal $100 D2753 Crown – porcelain fused to titanium and titanium alloys $100 D2780 Crown – ¾ cast high noble metal $100 D2781 Crown – ¾ cast predominantly base metal $100 D2782 Crown – ¾ cast noble metal $100 D2783 Crown – ¾ porcelain/ceramic $100 D2790 Crown – full cast high noble metal $100 D2791 Crown – full cast predominantly base metal $100 D2792 Crown – full cast noble metal $100 D2794 Crown – titanium and titanium alloys $100 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. $0 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 $113 D2930 Prefabricated stainless steel crown – primary tooth $0 D2931 Prefabricated stainless steel crown – permanent tooth $0 D2932 Prefabricated resin crown $0 D2933 Prefabricated stainless steel crown with resin window $0 D2940 Protective restoration $0 D2941 Interim therapeutic restoration - primary dentition $0 D2950 Core buildup, including any pins when required $15 D2951 Pin retention – per tooth, in addition to restoration $10 D2952 Post and core in addition to crown, indirectly fabricated $40 D2953 Each additional indirectly fabricated post – same tooth $40 D2954 Prefabricated post and core in addition to crown $40 D2955 Post removal $10 D2957 Each additional prefabricated post – same tooth $25 D2960 Labial veneer (resin laminate) – chairside $250 D2961 Labial veneer (resin laminate) – laboratory $300 D2962 Labial veneer (porcelain laminate) – laboratory $350

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 5 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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 $0 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 Endodontics • All procedures exclude final restoration. D3110 Pulp cap – direct (excluding final restoration) $0 D3120 Pulp cap – indirect (excluding final restoration) $0 D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament $0 D3221 Pulpal debridement, primary and permanent teeth $20 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $0 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $5 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $10 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $40 D3320 Endodontic therapy, premolar tooth (excluding final restoration) $65 D3330 Endodontic therapy, molar tooth (excluding final restoration) $95 D3331 Treatment of root canal obstruction; non-surgical access $55 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $50 D3333 Internal root repair of perforation defects: Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by same provider. $55 D3346 Retreatment of previous root canal therapy – anterior $65 D3347 Retreatment of previous root canal therapy – premolar $90 D3348 Retreatment of previous root canal therapy – molar $160 D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) $65 D3352 Apexification/recalcification – interim medication replacement $65 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $65 D3410 Apicoectomy – anterior $95 D3421 Apicoectomy – premolar (first root) $95 D3425 Apicoectomy – molar (first root) $95 D3426 Apicoectomy (each additional root) $60 D3430 Retrograde filling – per root $10 D3450 Root amputation – per root $95 D3471 Surgical repair of root resorption – anterior $72 D3472 Surgical repair of root resorption – premolar $72 D3473 Surgical repair of root resorption – molar $72

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 6 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D3910 Surgical procedure for isolation of tooth with rubber dam $19 D3920 Hemisection (including any root removal), not including root canal therapy $90 D3950 Canal preparation and fitting of preformed dowel or post $15 Periodontics D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant $50 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant $38 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. $100 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. $78 D4245 Apically positioned flap $165 D4249 Clinical crown lengthening – hard tissue $120 D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant $260 D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant $198 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

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 7 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D4270 Pedicle soft tissue graft procedure $195 D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft $75 D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) $70 D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft $265 D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft $195 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 $98 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 $133 D4322 Splint - intracoronal; natural teeth or prosthetic crowns $85 D4323 Splint - extracoronal; natural teeth or prosthetic crowns $75 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $25 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $19 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. $15 D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth $60 D4910 Periodontal maintenance $15 • Additional periodontal maintenance procedures (beyond 2 per 12 months) $40 • Periodontal charting for planning treatment of periodontal disease $0 • Periodontal hygiene instruction $0 Removable Prosthodontics • Includes up to 3 adjustments within 6 months of delivery. D5110 Complete denture - maxillary $125 D5120 Complete denture - mandibular $125 D5130 Immediate denture - maxillary $125 D5140 Immediate denture – mandibular $125 D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $110 D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $110 D5213 Maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $150 D5214 Mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $150 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) $110 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) $110

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 8 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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) $150 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) $150 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) $365 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) $365 D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth) $110 D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth) $110 D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary $150 D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular $150 D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant $75 D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant $75 D5410 Adjust complete denture – maxillary $0 D5411 Adjust complete denture – mandibular $0 D5421 Adjust partial denture – maxillary $0 D5422 Adjust partial denture – mandibular $0 D5511 Repair broken complete denture base, mandibular $15 D5512 Repair broken complete denture base, maxillary $15 D5520 Replace missing or broken teeth – complete denture (each tooth) $15 D5611 Repair resin partial denture base, mandibular $15 D5612 Repair resin partial denture base, maxillary $15 D5621 Repair cast partial framework, mandibular $15 D5622 Repair cast partial framework, maxillary $15 D5630 Repair or replace broken retentive clasping materials – per tooth $15 D5640 Replace broken teeth – per tooth $15 D5650 Add tooth to existing partial denture $15 D5660 Add clasp to existing partial denture - per tooth $15 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 $50 D5711 Rebase complete mandibular denture $50 D5720 Rebase maxillary partial denture $50 D5721 Rebase mandibular partial denture $50 D5725 Rebase hybrid prosthesis $50 D5730 Reline complete maxillary denture (chairside) $35 D5731 Reline complete mandibular denture (chairside) $35 D5740 Reline maxillary partial denture (chairside) $35 D5741 Reline mandibular partial denture (chairside) $35 D5750 Reline complete maxillary denture (laboratory) $40 D5751 Reline complete mandibular denture (laboratory) $40

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 9 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D5760 Reline maxillary partial denture (laboratory) $40 D5761 Reline mandibular partial denture (laboratory) $40 D5765 Soft liner for complete or partial removable denture – indirect $40 D5810 Interim complete denture (maxillary) $130 D5811 Interim complete denture (mandibular) $130 D5820 Interim partial denture (maxillary) $40 D5821 Interim partial denture (mandibular) $40 D5850 Tissue conditioning, maxillary $10 D5851 Tissue conditioning, mandibular $10 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 $32 D6089 Accessing and retorquing loose implant screw – per screw $0 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 D6197 Replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant. $25 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 crown/bridge unit in addition to regular co-payments for porcelain on molars. • Cases involving seven (7) or more crowns and/or fixed bridge units in the same treatment plan require an additional $125 co-payment per unit in addition to co-payment for each crown/bridge unit. D6210 Pontic – cast high noble metal $100 D6211 Pontic – cast predominantly base metal $100 D6212 Pontic – cast noble metal $100 D6214 Pontic – titanium and titanium alloys $100 D6240 Pontic – porcelain fused to high noble metal $100 D6241 Pontic – porcelain fused to predominantly base metal $100 D6242 Pontic – porcelain fused to noble metal $100 D6243 Pontic – porcelain fused to titanium and titanium alloys $100 D6245 Pontic – porcelain/ceramic $120 D6250 Pontic – resin with high noble metal $100 D6251 Pontic – resin with predominantly base metal $100 D6252 Pontic – resin with noble metal $100 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. $0 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6600 Retainer inlay – porcelain/ceramic, two surfaces $100 D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $100

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 10 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D6602 Retainer inlay – cast high noble metal, two surfaces $100 D6603 Retainer inlay – cast high noble metal, three or more surfaces $100 D6604 Retainer inlay – cast predominantly base metal, two surfaces $100 D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $100 D6606 Retainer inlay – cast noble metal, two surfaces $100 D6607 Retainer inlay – cast noble metal, three or more surfaces $100 D6608 Retainer onlay – porcelain/ceramic, two surfaces $100 D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $100 D6610 Retainer onlay – cast high noble metal, two surfaces $100 D6611 Retainer onlay – cast high noble metal, three or more surfaces $100 D6612 Retainer onlay – cast predominantly base metal, two surfaces $100 D6613 Retainer onlay – cast predominantly base metal, three or more surfaces $100 D6614 Retainer onlay – cast noble metal, two surfaces $100 D6615 Retainer onlay – cast noble metal, three or more surfaces $100 D6710 Retainer crown – indirect resin based composite $100 D6720 Retainer crown – resin with high noble metal $100 D6721 Retainer crown – resin with predominantly base metal $100 D6722 Retainer crown – resin with noble metal $100 D6740 Retainer crown – porcelain/ceramic $100 D6750 Retainer crown – porcelain fused to high noble metal $100 D6751 Retainer crown – porcelain fused to predominantly base metal $100 D6752 Retainer crown – porcelain fused to noble metal $100 D6753 Retainer crown – porcelain fused to titanium and titanium alloys $100 D6780 Retainer crown – ¾ cast high noble metal $100 D6781 Retainer crown – ¾ cast predominantly base metal $100 D6782 Retainer crown – ¾ cast noble metal $100 D6783 Retainer crown – ¾ porcelain/ceramic $100 D6784 Retainer crown – ¾ titanium and titanium alloys $100 D6790 Retainer crown – full cast high noble metal $100 D6791 Retainer crown – full cast predominantly base metal $100 D6792 Retainer crown – full cast noble metal $100 D6794 Retainer crown – titanium and titanium alloys $100 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 benefit unless pathology (disease) exists. D7111 Extraction, coronal remnants – primary tooth $0 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $15 D7220 Removal of impacted tooth – soft tissue $20 D7230 Removal of impacted tooth – partially bony $40 D7240 Removal of impacted tooth – completely bony $75

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 11 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $90 D7250 Removal of residual tooth roots (cutting procedure) $5 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. $75 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $15 D7280 Exposure of an unerupted tooth $15 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $15 D7283 Placement of an attachment on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280. $15 D7285 Incisional biopsy of oral tissue – hard (bone, tooth) $0 D7286 Incisional biopsy of oral tissue – soft $0 D7287 Exfoliative cytological sample collection $50 D7288 Brush biopsy – transepithelial sample collection $50 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $0 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $0 D7471 Removal of lateral exostosis (maxilla or mandible) $80 D7472 Removal of torus palatinus $15 D7473 Removal of torus mandibularis $15 D7485 Reduction of osseous tuberosity $60 D7510 Incision and drainage of abscess – intraoral soft tissue $15 D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $15 D7520 Incision and drainage of abscess – extraoral soft tissue $15 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $15 D7910 Suture of recent small wounds up to 5 cm $15 D7961 Buccal / labial frenectomy (frenulectomy) $0 D7962 lingual frenectomy (frenulectomy) $0 D7963 Frenuloplasty $0 D7970 Excision of hyperplastic tissue – per arch $55 D7971 Excision of pericoronal gingiva $35 Orthodontics • Benefits cover 24 months of usual & customary orthodontic treatment and 24 months of retention. • Comprehensive orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $725 D8020 Limited orthodontic treatment of the transitional dentition $725 D8030 Limited orthodontic treatment of the adolescent dentition $725 D8040 Limited orthodontic treatment of the adult dentition $725 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,450

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 12 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,450 D8090 Comprehensive orthodontic treatment of the adult dentition $1,450 D8210 Removable appliance therapy 25% Discount D8220 Fixed appliance therapy 25% Discount D8660 Pre-orthodontic treatment examination to monitor growth and development $0 D8670 Periodic orthodontic treatment visit $0 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $250 D8698 Re-cement or re-bond fixed retainer – maxillary $0 D8699 Re-cement or re-bond fixed retainer – mandibular $0 • Orthodontic treatment plan and records (pre/post x-rays (cephalometric, panoramic, etc.), photos, study models) $250 • Ortho visits beyond 24 months of active treatment or retention $25 per visit 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. $0 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 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 $15 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 D9942 Repair and/or reline of occlusal guard $40 D9944 Occlusal guard – hard appliance, full arch $85

GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 13 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D9945 Occlusal guard – soft appliance, full arch $85 D9946 Occlusal guard – hard appliance, partial arch $64 D9951 Occlusal adjustment – limited $0 D9952 Occlusal adjustment – complete $0 D9954 Fabrications and delivery of oral appliance therapy (OAT) morning repositioning device $16 D9972 External bleaching – per arch – performed in office $125 D9986 Missed appointment (less than 24-hr notice) Not to exceed $10 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association

GCERT2010-DHMO-SOB limit Customer Service (800) 880-1800 Page 14 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Dental benefits: Limitations and additional charges General 1. General anesthesia is a covered benefit only when administered by the treating dentist, in conjunction with oral and periodontal surgical procedures. Preventive 1. Routine Cleanings (prophylaxis), periodontal maintenance services, and fluoride treatments are limited to twice a year. Two (2) additional cleanings (routine and periodontal) are available at the co-payment listed on this Plan’s Schedule of Benefits. Additional prophylaxis are available, if medically necessary. 2. Sealants and/or preventive resin restorations: Plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption, unless medically necessary. Diagnostic 1. Panoramic or full-mouth X-rays: Once every three (3) years, unless medically necessary. Restorative 1. An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. 2. Replacement of any crowns or fixed bridges (per unit) are limited to once every five (5) years. 3. Cases involving seven (7) or more crowns 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/bridge unit. 4. There is a $75 co-payment per crown/bridge unit in addition to the specified co-payment for porcelain on molars. 5. 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. Prosthodontics 1. Relines 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 functioning tooth. 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 SafeGuard selected general dentist. 3. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 4. 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. Endodontics 1. The co-payments listed for endodontic procedures do not include the cost of the final restoration. Oral Surgery 1. The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists.

GCERT2010-DHMO-SOB exclusions Customer Service (800) 880-1800 Page 15 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Dental benefits: Exclusions 1. Any procedures not specifically listed as a covered benefit in this Plan’s Schedule of Benefits are not covered. 2. Services performed by any dentist not contracted with SafeGuard, without prior approval by SafeGuard (except out-of-area emergency services). This includes services performed by a general dentist or specialty care dentist. 3. Dental procedures started prior to the member’s eligibility under this Plan or started after the member’s termination from the Plan. Examples include: teeth prepared for crowns, root canals in progress, 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 the member’s dental health, as determined by the SafeGuard selected general dentist. 5. Orthognathic surgery. 6. Inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. 7. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen or damaged due to abuse, misuse, or neglect. 8. Treatment of malignancies, cysts, or neoplasms, unless specifically listed as a covered benefit on this Plan’s Schedule of Benefits. Any services related to pathology laboratory fees. 9. Procedures, appliances, or restorations whose primary main purpose is to change the vertical dimension of occlusion, correct congenital, 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 benefit on this Plan’s Schedule of Benefits. 10. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 11. 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. 12. Dental services required while serving in the Armed Forces of any country or international authority. 13. Dental services considered experimental in nature. 14. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member. Orthodontic Exclusions & Limitations If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment. If you 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. 1. Orthodontic treatment must be provided by a SafeGuard selected general dentist or SafeGuard contracted orthodontist in order for the co-payments listed in this Plan’s Schedule of Benefits to apply. 2. 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. 3. The following are not included as orthodontic benefits: A. Repair or replacement of lost or broken appliances; B. Retreatment of orthodontic cases; C. Treatment involving: i. Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; ii. Hormonal imbalances or other factors affecting growth or developmental abnormalities; iii. Treatment related to temporomandibular joint disorders; iv. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 4. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. 5. Active orthodontic treatment in progress on your effective date of coverage is not covered. Active orthodontic treatment means tooth movement has begun.

GCERT2010-DHMO-SOB Page 16 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f 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.