Local 272 Welfare Fund Group #272

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1 Effective March 1, 2019 Summary of Benefit for Full-Time Members: Local 272 Welfare Fund Group #272 Annual maximum $1,000 individual Deductible: $100 Individual/ $250 Family Dependent children are covered up to the end of the month they turn 26 Pre-Authorizations: Any claims over $ must be pre-authorized. In Network: Preventive, Basic and Major work paid at 100% of the Sele-Dent fee schedule- minus copays. Out of Network: Preventive, Basic and Major work paid at 100% of the Sele-Dent fee schedule, member pays balance. FREQUENCIES: Examination: Once every 6 months Prophylaxis: Once every 6 months Full Mouth & Panoramic X-Rays: Once every 3 years Fluoride: Once per calendar year up to age 16 Sealants: Once per calendar year up to age 16 Perio Scaling: Once every calendar year, all four quads same day, no prophy Major work: 5 years replacement on major Missing Tooth: Covered Anesthesia: Covered Exclusions: Implants and Veneers: Not covered Orthodontia: Not covered Charges not listed on the co-pay list Mailing Address: Toll Free: (800) One Huntington Quadrangle, Suite 1S03 Phone: (516) Melville, NY Fax: (516)

2 SELEDENT FEES WITH COPAYS EFF 3/1/19 Local COMPREHENSIVE ORAL EXAM $ $ 6.00 $ X-RAYS-COMPLETE SERIES $ $ $ X-RAYS-PERIAPICAL 1ST FILM $ 4.00 $ 1.00 $ X-RAYS-PERIAPICAL EACH ADD'L $ 3.00 $ 1.00 $ X-RAYS-OCCLUSAL FILM $ 9.00 $ 3.00 $ X-RAYS-1 BITEWING $ 5.00 $ 3.00 $ X-RAYS-2 BITEWINGS $ 9.00 $ 3.00 $ X-RAYS-4 BITEWINGS $ $ 6.00 $ X-RAYS-PANORAMIC FILM $ $ 9.00 $ BACTERIOLOGIC EXAM/TESTS $ $ 8.00 $ DIAGNOSTIC CASTS $ $ 5.00 $ DENTAL PROPHYLYLAXIS-ADULT $ $ 9.00 $ DENTAL PROPHYLYLAXIS-CHILD $ $ 7.00 $ FLOURIDE TREATMENT $ $ 4.00 $ SEALANT-PER TOOTH $ $ 6.00 $ SPACE MAINTAINER-FIXED UNILAT $ $ $ SPACE MAINTAINER-FIXED BILATER $ $ $ SPACE MAINTAINER-REMOV.UNILAT $ $ $ SPACE MAINTAINER-REMOV.BILATER $ $ $ AMALGAM-1 SURFACE, PRIM., PERM. $ $ 5.00 $ AMALGAM-2 SURFACES, PRIM., PERM. $ $ 9.00 $ AMALGAM-3 SURFACES, PRIM., PERM. $ $ $ AMALGAM-4+ SURFACES, PRIM., PERM. $ $ $ COMPOSITE-1 SURFACE, ANTERIOR $ $ 7.00 $ COMPOSITE-2 SURFACES, ANTERIOR $ $ $ COMPOSITE-3 SURFACES, ANTERIOR $ $ $ COMPOSITE-4+ SURF/INCISAL,ANT. $ $ $ COMPOSITE-1 SURFACE, POSTERIOR $ $ 7.00 $ COMPOSITE-2 SURFACES, POSTERIOR $ $ $ COMPOSITE-3 SURFACES, POSTERIOR $ $ $ COMPOSITE-4+ SURFACES, POSTERIOR $ $ $ INLAY-METALLIC-1 SURFACE $ $ $ INLAY-METALLIC-2 SURFACES $ $ $ INLAY-METALLIC-3 OR MORE SURFACES $ $ $ CROWN-RESIN (LABORATORY) $ $ $ CROWN-RESIN HIGH NOBLE METAL $ $ $ CROWN-RESIN PREDOM BASE METAL $ $ $ CROWN-RESIN NOBLE METAL $ $ $ CROWN-PORCELAIN/CERAMIC $ $ $ CROWN-PORCELAIN PREDOM BASE METAL $ $ $ CROWN-PORCELAIN NOBLE METAL $ $ $ CROWN-3/4 CAST HIGH NOBLE METAL $ $ $

3 2790 CROWN-FULL CAST HIGH NOBLE METAL $ $ $ CROWN-FULL CAST PREDOM BASE $ $ $ CROWN-FULL CAST NOBLE METAL $ $ $ RECEMENT INLAY $ $ 6.00 $ RECEMENT CROWN $ $ 7.00 $ STAINLESS STEEL CROWN-PRIM. $ $ $ STAINLESS STEEL CROWN-PERM. $ $ $ PIN RETENTION-PER TOOTH $ $ 5.00 $ CAST POST AND CORE $ $ $ PREFABRICATED POST AND CORE $ $ $ PULP CAP-DIRECT $ $ 4.00 $ PULP CAP-INDIRECT $ $ 4.00 $ THERAPEUTIC PULPOTOMY $ $ ROOT CANAL-ANTERIOR $ $ $ ROOT CANAL-BICUSPID $ $ $ ROOT CANAL-MOLAR $ $ $ APICOECTOMY-ANTERIOR $ $ $ APICOECTOMY-BICUSPID, 1ST ROOT $ $ $ APICOECTOMY-MOLAR, 1ST ROOT $ $ $ APICOECTOMY-EACH ADD'L ROOT $ $ $ GINGIVECTOMY/PLASTY-PER QUAD $ $ $ GINGIVECTOMY/PLASTY-1 TO 3 TTH $ $ 6.00 $ OSSEOUS SURGERY-PER QUAD $ $ $ PERIO SCALING/RT PLANNING-QUAD $ $ $ COMPLETE DENTURE-MAXILLARY $ $ $ COMPLETE DENTURE-MANDIBULAR $ $ $ IMMEDIATE DENTURE-MAXILLARY $ $ $ IMMEDIATE DENTURE-MANDIBULAR $ $ $ PRTL DENT-MAX W/CLASPS-ACRYLIC $ $ $ PRTL DENT-MAND W/CLASPS-ACRYLIC $ $ $ PRTL DENT-MAX W/CLASPS-CAST $ $ $ PRTL DENT-MAND W/CLASPS-CAST $ $ $ REMOVABLE UNILATERAL PRTL-1TTH $ $ $ ADJUST COMPLETE DENTURE-MAX $ $ $ ADJUST COMPLETE DENTURE-MAND $ $ $ ADJUST PARTIAL DENTURE-MAX $ $ $ ADJUST PARTIAL DENTURE-MAND $ $ $ REPAIR BRKN COMPLETE DENT BASE $ $ $ REPLACE MISS/BRKN TTH-COMP DNT $ $ $ REPAIR PRTL RESIN DENTURE BASE $ $ $ REPAIR PARTIAL CAST FRAMEWORK $ $ $ REPAIR/REPLACE BROKEN CLASP $ $ $ REPLACE BROKEN TEETH-PER TOOTH $ $ $ ADD TOOTH TO PARTIAL DENTURE $ $ $ ADD CLASP TO PARTIAL DENTURE $ $ $

4 5710 REBASE COMPLETE DENTURE-MAX $ $ $ REBASE COMPLETE DENTURE-MAND $ $ $ REBASE PARTIAL DENTURE-MAX $ $ $ REBASE PARTIAL DENTURE-MAND $ $ $ RELINE COMPLETE DENT-MAX-CHAIR $ $ $ RELINE COMPLETE DENT-MAND-CHAIR $ $ $ RELINE PARTIAL DENT-MAX-CHAIR $ $ $ RELINE PARTIAL DENT-MAND-CHAIR $ $ $ RELINE COMPLETE DENT-MAX-LAB $ $ $ RELINE COMPLETE DENT-MAND-LAB $ $ $ RELINE PARTIAL DENT-MAX-LAB $ $ $ RELINE PARTIAL DENT-MAND-LAB $ $ $ PONTIC-CAST HIGH NOBLE METAL $ $ $ PONTIC-CAST PREDOM BASE METAL $ $ $ PONTIC-CAST NOBLE METAL $ $ $ PONTIC-PORCE PREDOM BASE METAL $ $ $ PONTIC-PORCELAIN NOBLE METAL $ $ $ PONTIC-RESIN HIGH NOBLE METAL $ $ $ PONTIC-RESIN PREDOM BASE METAL $ $ $ PONTIC-RESIN NOBLE METAL $ $ $ RETAINER-CAST METAL MARYLAND $ $ $ INLAY-PORCE/CERAMIC-2 SURFACES $ $ INLAY-PORCE/CERAMIC 3+ SURFACES $ $ ABUTMENT-RESIN HIGH NOBLE MTL $ $ $ ABUTMENT-PORCELAIN NOBLE METAL $ $ $ ABUTMENT-PORCELAIN/CERAMIC $ $ $ ABUTMENT-PORCE PREDOM BASE MTL $ $ $ ABUTMENT-PORCELAIN NOBLE METAL $ $ $ ABUTMENT-3/4 CAST HIGH NOBLE $ $ $ ABUTMENT-FULL CAST HIGH NOBLE $ $ $ RECEMENT BRIDGE $ $ $ EXTRACTION-ERUPTED TTH-EXPOSED $ $ $ SURGICAL REMOVAL ERUPTED TOOTH $ $ $ REMOVAL IMPACTED TTH-SOFT TISS $ $ $ REMOVAL IMPACTED TTH-PRTL BONY $ $ $ REMOVAL IMPACTED TTH-FULL BONY $ $ $ OROANTRAL FISTULA CLOSURE $ $ $ SURG EXP. IMPACTED TTH-ORTHO $ $ $ SURG EXP. IMPACTED TTH-AID ERUP $ $ $ BIOPSY OF ORAL TISSUE-HARD $ $ $ BIOPSY OF ORAL TISSUE-SOFT $ $ ALVEOLOPLASTY W/EXT-QUAD $ $ $ ALVEOLOPLASTY W/O EXT-QUAD $ $ $ REMOVAL OF EXOSTOSIS-PER SITE $ $ $ INCISION & DRAINAGE INTRAORAL $ $ $ INCISION & DRAINAGE EXTRAORAL $ $ $ FRENULECTOMY-(FRENECTOMY) $ $ $

5 7970 EXCISION HYPERPLASTIC TIS-ARCH $ $ $ PALLIATIVE TREATMENT $ $ 7.00 $ DEEP SED/GEN ANESTH-1ST 30 MIN $ $ $ DEEP SED/GEN ANESTH-EA. ADDL 15 $ $ $ CONSULTATION BY SPECIALIST $ $ $