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Exhibit 2 Dental Fee Schedule CDT D0120 D0140 D0150 Description periodic oral evaluation - established patient limited oral evaluation - problem focused comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral evaluation - problem focused, by report re-evaluation - limited, problem focused (established patient; not post-operative visit) 190 168 85 75 comprehensive periodontal evaluation - new or established patient intraoral - complete series (including bitewings) intraoral - periapical first film intraoral - periapical each additional film intraoral - occlusal film extraoral - first film extraoral - each additional film bitewing - single film bitewings - two films bitewings - three films bitewings - four films vertical bitewings - 7 to 8 films posterior-anterior or lateral skull and facial bone survey film temporomandibular joint arthrogram, including injection other temporomandibular joint films, by report panoramic film cephalometric film oral/facial photographic images cone beam ct - craniofacial data capture cone beam - two-dimensional image reconstruction using existing data, includes multiple images cone beam - three-dimensional image reconstruction using existing data, includes multiple images pulp vitality tests diagnostic casts prophylaxis - adult prophylaxis - child sealant - per tooth space maintainer - fixed - unilateral space maintainer - fixed - bilateral space maintainer - removable - unilateral space maintainer - removable - bilateral re-cementation of space maintainer removal of fixed space maintainer amalgam - one surface, primary or permanent amalgam - two surfaces, primary or permanent amalgam - three surfaces, primary or permanent amalgam - four or more surfaces, primary or permanent resin-based composite - one surface, anterior resin-based composite - two surfaces, anterior resin-based composite - three surfaces, anterior resin-based composite - four or more surfaces or involving incisal angle (anterior) resin-based composite crown, anterior resin-based composite - one surface, posterior resin-based composite - two surfaces, posterior resin-based composite - three surfaces, posterior resin-based composite - four or more surfaces, posterior gold foil - one surface 113 153 34 28 51 80 68 34 53 67 78 119 164 714 248 130 147 88 691 100 135 30 25 45 71 60 30 47 59 69 105 145 632 219 115 130 78 611 448 397 482 67 135 108 79 65 374 509 457 578 101 93 169 213 256 305 190 238 298 427 59 119 95 70 57 330 451 405 512 89 82 149 188 226 269 168 210 263 374 549 209 276 338 408 772 330 486 185 244 299 361 683 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0290 D0320 D0321 D0330 D0340 D0350 D0360 D0362 D0363 D0460 D0470 D1110 D1120 D1351 D1510 D1515 D1520 D1525 D1550 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410 NORTH SOUTH 59 52 91 80 104 92 Exhibit 2 Dental Fee Schedule CDT D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2930 D2931 D2932 D2933 Description gold foil - two surfaces gold foil - three surfaces inlay - metallic - one surface inlay - metallic - two surfaces inlay - metallic - three or more surfaces onlay - metallic-two surfaces onlay - metallic-three surfaces onlay - metallic-four or more surfaces inlay - porcelain/ceramic - one surface inlay - porcelain/ceramic - two surfaces inlay - porcelain/ceramic - three or more surfaces onlay - porcelain/ceramic - two surfaces onlay - porcelain/ceramic - three surfaces onlay - porcelain/ceramic - four or more surfaces inlay - resin-based composite - one surface inlay - resin-based composite - two surfaces inlay - resin-based composite - three or more surfaces onlay - resin-based composite - two surfaces onlay - resin-based composite - three surfaces onlay - resin-based composite - four or more surfaces crown - resin-based composite (indirect) crown - 3/4 resin-based composite (indirect) crown - resin with high noble metal crown - resin with predominantly base metal crown - resin with noble metal crown - porcelain/ceramic substrate crown - porcelain fused to high noble metal crown - porcelain fused to predominantly base metal crown - porcelain fused to noble metal crown - 3/4 cast high noble metal crown - 3/4 cast predominantly base metal crown - 3/4 cast noble metal crown - 3/4 porcelain/ceramic crown - full cast high noble metal crown - full cast predominantly base metal crown - full cast noble metal crown - titanium provisional crown recement inlay, onlay, or partial coverage restoration recement cast or prefabricated post and core recement crown prefabricated stainless steel crown - primary tooth prefabricated stainless steel crown - permanent tooth prefabricated resin crown prefabricated stainless steel crown with resin window D2934 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 prefabricated esthetic coated stainless steel crown - primary tooth protective restoration core buildup, including any pins pin retention - per tooth, in addition to restoration post and core in addition to crown, indirectly fabricated each additional indirectly fabricated post - same tooth prefabricated post and core in addition to crown post removal (not in conjunction with endodontic therapy) each additional prefabricated post - same tooth labial veneer (resin laminate) - chairside labial veneer (resin laminate) - laboratory NORTH SOUTH 860 761 938 830 1019 901 1073 949 1135 1005 1183 1047 1200 1062 1224 1083 1070 946 1142 1011 1189 1052 1193 1056 1245 1102 1302 1152 1041 921 1070 946 1108 980 1121 991 1168 1034 1223 1082 1123 993 1197 1059 1245 1102 1189 1052 1201 1063 1358 1202 1302 1152 1245 1102 1247 1104 1250 1106 1215 1075 1202 1064 1297 1148 1305 1155 1189 1052 1238 1096 1280 1133 526 466 130 115 135 119 130 115 321 284 386 342 417 369 440 390 432 146 323 89 504 374 396 350 243 797 1160 383 129 285 79 446 330 351 309 215 705 1027 Exhibit 2 Dental Fee Schedule CDT D2962 D2970 D2971 D2975 D2980 D3310 D3320 D3330 D4210 D4249 D4260 D4261 D4263 D4341 D4355 Description NORTH SOUTH labial veneer (porcelain laminate) - laboratory 1360 1203 temporary crown (fractured tooth) 453 401 additional procedures to construct new crown under existing partial denture framework 246 217 coping 717 634 crown repair, by report 351 310 endodontic therapy, anterior tooth (excluding final restoration) 865 765 endodontic therapy, bicuspid tooth (excluding final restoration) 996 881 endodontic therapy, molar (excluding final restoration) 1198 1060 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 764 676 clinical crown lengthening - hard tissue 912 807 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant 1272 1126 osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant 1075 951 bone replacement graft - first site in quadrant 851 753 periodontal scaling and root planing - four or more teeth per quadrant 300 265 full mouth debridement to enable comprehensive evaluation and diagnosis 217 192 D5212 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report periodontal maintenance complete denture - maxillary complete denture - mandibular immediate denture - maxillary immediate denture - mandibular maxillary partial denture - resin base (including any conventional clasps, rests and teeth) mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 2126 1881 D5214 D5510 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) repair broken complete denture base 2126 252 1881 223 D5520 D5610 D5620 D5630 D5640 D5650 D5660 replace missing or broken teeth - complete denture (each tooth) repair resin denture base repair cast framework repair or replace broken clasp replace broken teeth - per tooth add tooth to existing partial denture add clasp to existing partial denture 223 242 345 316 218 267 323 197 214 305 279 193 236 285 D5670 replace all teeth and acrylic on cast metal framework (maxillary) 890 787 D5671 D5710 D5711 D5720 D5721 D5730 replace all teeth and acrylic on cast metal framework (mandibular) rebase complete maxillary denture rebase complete mandibular denture rebase maxillary partial denture rebase mandibular partial denture reline complete maxillary denture (chairside) 901 692 686 668 668 441 797 612 607 591 591 391 D4381 D4910 D5110 D5120 D5130 D5140 D5211 180 166 2038 2042 2207 2207 159 147 1803 1807 1953 1953 1613 1427 1613 1427 Exhibit 2 Dental Fee Schedule CDT D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D6060 Description NORTH SOUTH reline complete mandibular denture (chairside) 440 390 reline maxillary partial denture (chairside) 432 383 reline mandibular partial denture (chairside) 440 390 reline complete maxillary denture (laboratory) 565 500 reline complete mandibular denture (laboratory) 566 501 reline maxillary partial denture (laboratory) 560 496 reline mandibular partial denture (laboratory) 560 496 interim complete denture (maxillary) 1029 910 interim complete denture (mandibular) 1043 922 interim partial denture (maxillary) 834 738 interim partial denture (mandibular) 834 738 tissue conditioning, maxillary 249 220 tissue conditioning, mandibular 249 220 overdenture - complete, by report 2537 2244 overdenture - partial, by report 2477 2191 precision attachment, by report 849 751 replacement of replaceable part of semi-precision or precision attachment (male or female component) 462 409 modification of removable prosthesis following implant surgery 466 413 trismus appliance (not for TMD treatment) 882 780 feeding aid 1031 912 surgical stent 529 468 surgical splint 902 799 surgical placement of implant body: endosteal implant 2377 2103 surgical placement of interim implant body for transitional prosthesis: endosteal implant 1872 1656 surgical placement: eposteal implant 9819 8687 surgical placement: transosteal implant 6885 6091 implant/abutment supported removable denture for completely edentulous arch 3386 2995 implant/abutment supported removable denture for partially edentulous arch 3321 2938 connecting bar - implant supported or abutment supported 3506 3102 prefabricated abutment - includes placement 962 851 custom abutment - includes placement 1132 1002 abutment supported porcelain/ceramic crown 1727 1528 abutment supported porcelain fused to metal crown (high noble metal) 1734 1534 abutment supported porcelain fused to metal crown (predominantly base metal) 1626 1438 D6061 D6062 abutment supported porcelain fused to metal crown (noble metal) abutment supported cast metal crown (high noble metal) 1622 1698 1435 1502 D6063 D6064 D6065 abutment supported cast metal crown (predominantly base metal) abutment supported cast metal crown (noble metal) implant supported porcelain/ceramic crown implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) implant supported metal crown (titanium, titanium alloy, high noble metal) abutment supported retainer for porcelain/ceramic FPD abutment supported retainer for porcelain fused to metal FPD (high noble metal) abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 1586 1623 1824 1403 1436 1613 1838 1626 1855 1731 1641 1531 1729 1529 1641 1452 D5867 D5875 D5937 D5951 D5982 D5988 D6010 D6012 D6040 D6050 D6053 D6054 D6055 D6056 D6057 D6058 D6059 D6066 D6067 D6068 D6069 D6070 Exhibit 2 Dental Fee Schedule CDT D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6080 D6090 D6091 D6092 D6093 D6094 D6095 D6100 D6190 D6194 D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 Description NORTH SOUTH abutment supported retainer for porcelain fused to metal FPD (noble metal) 1643 1453 abutment supported retainer for cast metal FPD (high noble metal) abutment supported retainer for cast metal FPD (predominantly base metal) abutment supported retainer for cast metal FPD (noble metal) implant supported retainer for ceramic FPD implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) implant/abutment supported fixed denture for completely edentulous arch implant/abutment supported fixed denture for partially edentulous arch implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis repair implant supported prosthesis, by report replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment recement implant/abutment supported crown recement implant/abutment supported fixed partial denture abutment supported crown - (titanium) repair implant abutment, by report implant removal, by report radiographic/surgical implant index, by report abutment supported retainer crown for FPD - (titanium) pontic - indirect resin based composite pontic - cast high noble metal pontic - cast predominantly base metal pontic - cast noble metal pontic - titanium pontic - porcelain fused to high noble metal pontic - porcelain fused to predominantly base metal pontic - porcelain fused to noble metal pontic - porcelain/ceramic pontic - resin with high noble metal pontic - resin with predominantly base metal pontic - resin with noble metal provisional pontic retainer - cast metal for resin bonded fixed prosthesis retainer - porcelain/ceramic for resin bonded fixed prosthesis crown - indirect resin based composite crown - resin with high noble metal crown - resin with predominantly base metal crown - resin with noble metal crown - porcelain/ceramic crown - porcelain fused to high noble metal crown - porcelain fused to predominantly base metal crown - porcelain fused to noble metal crown - 3/4 cast high noble metal crown - 3/4 cast predominantly base metal crown - 3/4 cast noble metal crown - 3/4 porcelain/ceramic 1741 1540 1635 1603 1813 1446 1418 1604 1854 1640 1870 1654 6621 5858 4784 4232 375 889 331 786 752 189 216 1590 863 904 509 1721 1156 1296 1201 1233 1292 1319 1215 1245 1358 1255 1244 1228 910 1019 1122 1192 1253 1242 1245 1364 1330 1217 1245 1271 1218 1245 1296 665 167 191 1407 763 800 451 1522 1023 1147 1063 1091 1143 1167 1075 1102 1202 1111 1101 1087 805 901 992 1055 1109 1099 1102 1207 1177 1077 1102 1125 1078 1102 1147 Exhibit 2 Dental Fee Schedule CDT D6790 D6791 D6792 D6793 D6794 D6920 D6930 D6940 D6950 D6970 D6972 D6973 D6975 D6976 D6977 D6980 D6985 D7110 D7111 D7120 D7140 D7210 D7250 D7290 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7771 D7780 D7810 D7820 D7830 D7840 D7850 D7852 Description NORTH SOUTH crown - full cast high noble metal 1298 1149 crown - full cast predominantly base metal 1201 1063 crown - full cast noble metal 1233 1091 provisional retainer crown 661 585 crown - titanium 1250 1106 connector bar 1182 1046 recement fixed partial denture 205 181 stress breaker 528 467 precision attachment 789 698 post and core in addition to fixed partial denture retainer, indirectly fabricated 517 458 prefabricated post and core in addition to fixed partial denture retainer 406 360 core build up for retainer, including any pins 323 285 coping - metal 832 736 each additional indirectly fabricated post - same tooth 343 303 each additional prefabricated post - same tooth 246 217 fixed partial denture repair, by report 455 403 pediatric partial denture, fixed 1073 949 single tooth (extraction) n/a n/a extraction, coronal remnants - deciduous tooth 161 142 each add tooth (extraction) n/a n/a extraction, erupted tooth or exposed root (elevation and/or forceps removal) 209 185 surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 328 290 surgical removal of residual tooth roots (cutting procedure) 370 327 surgical repositioning of teeth 625 553 maxillary sinusotomy for removal of tooth fragment or foreign body maxilla - open reduction (teeth immobilized, if present) maxilla - closed reduction (teeth immobilized, if present) mandible - open reduction (teeth immobilized, if present) mandible - closed reduction (teeth immobilized, if present) malar and/or zygomatic arch - open reduction malar and/or zygomatic arch - closed reduction alveolus closed reduction may include stabilization of teeth alveolus, open reduction may include stabilization of teeth facial bones - complicated reduction with fixation and multiple surgical approaches maxilla open reduction maxilla - closed reduction mandible - open reduction mandible - closed reduction malar and/or zygomatic arch - open reduction malar and/or zygomatic arch - closed reduction alveolus - open reduction stabilization of teeth alveolus, closed reduction stabilization of teeth facial bones - complicated reduction with fixation and multiple surgical approaches open reduction of dislocation closed reduction of dislocation manipulation under anesthesia condylectomy surgical discectomy, with/without implant disc repair 1681 5162 4180 5349 4157 4631 3862 2257 1512 1487 4567 3699 4732 3678 4097 3417 1997 1338 7759 5260 4133 5746 4273 5014 7186 3294 2287 6864 4654 3656 5084 3781 4436 6358 2914 2023 10128 5014 763 1166 6424 6210 6609 8960 4436 675 1032 5684 5494 5847 Exhibit 2 Dental Fee Schedule CDT D7854 D7856 D7880 D7910 D7911 D7912 D7920 D7955 D7960 D7990 D8210 D8220 D8691 D8692 D8693 D9110 D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9410 D9420 D9430 D9610 D9612 D9630 D9940 D9950 D9951 D9952 Description NORTH SOUTH synovectomy 6140 5432 myotomy 4188 3706 occlusal orthotic device, by report 1453 1376 suture of recent small wounds up to 5 cm 368 325 complicated suture - up to 5 cm 610 540 complicated suture - greater than 5 cm 961 850 skin graft (identify defect covered, location and type of graft) 3110 2751 repair of maxillofacial soft and/or hard tissue defect 4554 3941 frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure 538 476 emergency tracheotomy 1715 1517 removable appliance therapy 1034 914 fixed appliance therapy 1174 1039 repair of orthodontic appliance 255 225 replacement of lost or broken retainer 405 359 rebonding or recementing; and/or repair, as required, of fixed retainers 408 361 palliative (emergency) treatment of dental pain - minor procedure local anesthesia not in conjunction with operative or surgical procedures regional block anesthesia trigeminal division block anesthesia local anesthesia in conjunction with operative or surgical procedures deep sedation/general anesthesia - first 30 minutes deep sedation/general anesthesia - each additional 15 minutes inhalation of nitrous oxide / anxiolysis, analgesia intravenous conscious sedation/analgesia - first 30 minutes intravenous conscious sedation/analgesia - each additional 15 minutes non-intravenous conscious sedation consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician house/extended care facility call hospital or ambulatory surgical center call office visit for observation (during regularly scheduled hours) - no other services performed therapeutic parenteral drug, single administration therapeutic parenteral drugs, two or more administrations, different medications other drugs and/or medicaments, by report occlusal guard, by report occlusion analysis - mounted case occlusal adjustment - limited occlusal adjustment - complete 154 136 91 113 317 80 100 280 79 480 205 96 509 70 425 181 85 451 200 400 177 354 158 301 357 140 266 315 94 131 83 116 226 63 727 418 223 846 200 56 643 370 197 748
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