Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

DIAGNOSTIC SERVICES

In Network

Out Of Network

D0120 D0140 D0145 D0150 D0160 D0170 D0171 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0330 D0340 D0350 D0460 D0470 D0472 D0473 D0474

Periodic oral evaluation, established patient Limited oral evaluation, problem focused Oral evaluation for a patient under three years of age and counseling with primary caregiver Comprehensive oral evaluation, new or established patient Detailed and extensive oral evaluation, problem focused, by report Re-evaluation, limited, problem focused (established patient; non post-operative visit) Re-evaluation, post operative office visit Comprehensive periodontal evaluation, new or established patient Intraoral, complete series of radiographic images Intraoral, periapical first radiographic image Intraoral, periapical each additional radiographic image Intraoral, occlusal radiographic image Extraoral, first radiographic image Extraoral, each additional radiographic image Bitewing, single radiographic image Bitewings, two radiographic images Bitewings, three radiographic images Bitewings, four radiographic images Vertical bitewings, 7 to 8 radiographic images Panoramic radiographic image Cephalometric radiographic image 2D oral/facial photographic image obtained intra-orally or extra-orally Pulp vitality tests Diagnostic casts Accession of tissue, gross exam, prep & transmission written report Accession of tissue, gross & micro exam, prep & transmission written report Accession of tissue, gross & micro exam, include assessment of surgical margin, prep & transmission written report

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100%

100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 50% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME*

D1110 D1120 D1206 D1208 D1351 D1352 D1353 D1510 D1515 D1520 D1525 D1550 D1555

Prophylaxis, adult Prophylaxis, child Topical application of fluoride varnish Topical application of fluoride, excluding varnish Sealant, per tooth Preventive resin restoration in a moderate to high caries risk patient, permanent tooth Sealant repair, per tooth Space maintainer, fixed, unilateral Space maintainer, fixed, bilateral Space maintainer, removable, unilateral Space maintainer, removable, bilateral Re-cement or re-bond space maintainer Removal of fixed space maintainer

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME* 100% EME*

D2140 D2150 D2160 D2161 D2330 D2331

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

80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

PREVENTIVE SERVICES

RESTORATIVE SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 1 of 11

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D2332 Resin-based composite, three surfaces, anterior D2335 D2390 D2391 D2392 D2393 D2394 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 D2910 D2915 D2920 D2930 D2931 D2932

RESTORATIVE SERVICES (continued)

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 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, ¾ 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, ¾ cast high noble metal Crown, ¾ cast predominantly base metal Crown, ¾ cast noble metal Crown, ¾ porcelain/ceramic Crown, full cast high noble metal Crown, full cast predominantly base metal Crown, full cast noble metal Crown, titanium Re-cement or re-bond inlay, onlay, veneer, or partial coverage Re-cement or re-bond indirectly fabricated or prefabricated post and core Re-cement or re-bond crown Prefabricated stainless steel crown, primary tooth Prefabricated stainless steel crown, permanent tooth Prefabricated resin crown

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 2 of 11

In Network 80%

Out Of Network 80% EME*

80% 80% 80% 80% 80% 80% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 80% 80% 80% 50% 50% 50%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 80% EME* 80% EME* 80% EME* 50% EME* 50% EME* 50% EME*

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown, primary tooth

RESTORATIVE SERVICES (continued)

In Network 50% 50%

Out Of Network 50% EME* 50% EME*

D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2971 D2980

Protective restoration Core buildup, including any pins when required 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 Each additional prefabricated post, same tooth Labial veneer (resin laminate), chairside Labial veneer (resin laminate), laboratory Labial veneer (porcelain laminate), laboratory Additional procedures to construct new crown under existing partial denture framework Crown repair necessitated by restorative material failure

80% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

80% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME*

D3110 D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3920

Pulp cap, direct (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling), anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling), posterior, primary tooth (excluding finale restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Treatment of root canal obstruction; non-surgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Internal root repair of perforation defects Retreatment of previous root canal therapy, anterior Retreatment of previous root canal therapy, bicuspid Retreatment of previous root canal therapy, molar Apexification recalcification, initial visit Apexification recalcification, interim medication replacement Apexification recalcification, final visit (includes completed root canal therapy) Apicoectomy, anterior Apicoectomy, bicuspid (first root) Apicoectomy, molar (first root) Apicoectomy, (each additional root) Retrograde filling, per root Root amputation, per root Hemisection (including any root removal), not including root canal therapy

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

D4210 D4211 D4230 D4231 D4240 D4241 D4245

Gingivectomy or gingivoplasty, four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty, one to three contiguous teeth or tooth bounded spaces per quadrant Anatomical crown exposure, four or more contiguous teeth per quadrant Anatomical crown exposure, one to three teeth per quadrant Gingival flap procedure, including root planing, four or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing, one to three contiguous teeth or tooth bounded spaces per quadrant Apically positioned flap

80% 80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

ENDODONTIC SERVICES

PERIODONTIC SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 3 of 11

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D4249 Clinical crown lengthening, hard tissue

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 4 of 11

In Network 80%

Out Of Network 80% EME*

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

PERIODONTIC SERVICES (continued)

D4263 D4264 D4265 D4266 D4268 D4270 D4273 D4274 D4275 D4277 D4278 D4341 D4342 D4355 D4381 D4910 D4920

Osseous surgery (including elevation of a full thickness flap and closure),four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including elevation of a full thickness flap and closure), one to three contiguous teeth or tooth bounded spaces per quadrant Bone replacement graft, first site in quadrant Bone replacement graft, each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration, resorbable barrier, per site Surgical revision procedure, per tooth Pedicle soft tissue graft procedure Subepithelial connective tissue graft procedures, per tooth Distal or proximal wedge procedure (when not performed in conjunction with surficial procedures in the same anatomica Soft tissue allograft Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth pos Periodontal scaling and root planing, four or more teeth per quadrant Periodontal scaling and root planing, one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth Periodontal maintenance Unscheduled dressing change (by someone other than treating dentist)

D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710

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) Maxillary partial denture, cast metal framework with resin denture bases Mandibular partial denture, cast metal framework with resin denture bases Maxillary partial denture, flexible base (including any clasps, rests and teeth) Mandibular partial denture, flexible base (including any clasps, rests and teeth) Removable unilateral partial denture, one piece cast metal (including clasps and teeth) Adjust complete denture, maxillary Adjust complete denture, mandibular Adjust partial denture, maxillary Adjust partial denture, mandibular Repair broken complete denture base 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 Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) Rebase complete maxillary denture

D4260 D4261

PROSTHODONTIC-REMOVABLE SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 5 of 11

In Network

Out Of Network

80%

80% EME*

80%

80% EME*

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME*

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D5711 Rebase complete mandibular denture

PROSTHODONTIC-REMOVABLE SERVICES(Continued)

In Network 50%

Out Of Network 50% EME*

D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851 D5863 D5865

Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary Tissue conditioning, mandibular Overdenture, complete maxillary Overdenture, complete mandibular

50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME*

D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6624 D6608 D6609 D6610 D6611 D6612 D6613

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 Retainer, cast metal for resin bonded fixed prosthesis Retainer, porcelain/ceramic for resin bonded fixed prosthesis Resin retainer, for resin bonded fixed prosthesis Inlay, porcelain/ceramic, two surfaces Inlay, porcelain/ceramic, three or more surfaces Inlay, cast high noble metal, two surfaces Inlay, cast high noble metal, three or more surfaces Inlay, cast predominantly base metal, two surfaces Inlay, cast predominantly base metal, three or more surfaces Inlay, cast noble metal, two surfaces Inlay, cast noble metal, three or more surfaces Inlay, titanium Onlay, porcelain/ceramic, two surfaces Onlay, porcelain/ceramic, three or more surfaces Onlay, cast high noble metal, two surfaces Onlay, cast high noble metal, three or more surfaces Onlay, cast predominantly base metal, two surfaces Onlay, cast predominantly base metal, three or more surfaces

50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME*

PROSTHODONTIC-FIXED SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 6 of 11

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D6614 Onlay, cast noble metal, two surfaces D6615 Onlay, cast noble metal, three or more surfaces

PROSTHODONTIC-FIXED SERVICES (Continued)

In Network 50% 50%

Out Of Network 50% EME* 50% EME*

D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6930 D6940 D6980

Onlay, titanium 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, ¾ cast high noble metal Crown, ¾ cast predominantly base metal Crown, ¾ cast noble metal Crown, ¾ porcelain/ceramic Crown, full cast high noble metal Crown, full cast predominantly base metal Crown, full cast noble metal Crown, titanium Re-cement or re-bond fixed partial denture Stress breaker Fixed partial denture repair necessitated by restorative

50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME* 50% EME*

D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7261 D7270 D7280 D7282 D7283 D7285 D7286 D7310 D7311 D7320 D7321 D7340

Extraction, coronal remnants, deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Removal of impacted tooth, soft tissue Removal of impacted tooth, partially bony Removal of impacted tooth, completely bony Removal of impacted tooth, completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Oroantral fistula closure Primary closure of a sinus perforation Primary closure of a sinus perforation Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Surgical access of an unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of device to facilitate eruption of impacted tooth Incisional biopsy of oral tissue, hard (bone, tooth) Incisional biopsy of oral tissue, soft Alveoloplasty in conjunction with extractions, four or more teeth or tooth spaces, per quadrant Alveoloplasty in conjunction with extractions, one to three teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions, four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions, one to three teeth or tooth spaces, per quadrant Vestibuloplasty, ridge extension (secondary epithelialization) Vestibuloplasty, ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Excision of benign lesion up to 1.25 cm Excision of benign lesion greater than 1.25 cm Excision of benign lesion, complicated

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

80%

80% EME*

80% 80% 80%

80% EME* 80% EME* 80% EME*

D7350 D7410 D7411 D7412

ORAL AND MAXILLOFACIAL SURGERY SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

Page 7 of 11

LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

D7450 Removal of benign odontogenic cyst or tumor, lesion diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor, lesion diameter greater than 1.25 cm

ORAL AND MAXILLOFACIAL SURGERY SERVICES (Continued)

In Network 80% 80%

Out Of Network 80% EME* 80% EME*

D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521 D7530 D7540 D7560 D7960 D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983

Removal of lateral exostosis (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Incision and drainage of abscess, intraoral soft tissue Incision and drainage of abscess, intraoral soft tissue, complicated (includes drainage of multiple fascial spaces) Incision and drainage of abscess, extraoral soft tissue Incision and drainage of abscess, extraoral soft tissue, complicated (includes drainage of multiple fascial spaces) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Removal of reaction producing foreign bodies, musculoskeletal system Maxillary sinusotomy for removal of tooth fragment or foreign body Frenulectomy, also known as frenectomy or frenotomy, separate procedure not incidental to another procedure Frenuloplasty Excision of hyperplastic tissue, per arch Excision of pericoronal gingiva Surgical reduction of fibrous tuberosity Sialolithotomy Excision of salivary gland, by report Sialodochoplasty Closure of salivary fistula

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME*

D9110 D9120 D9219 D9220 D9221 D9241 D9242 D9310 D9430 D9440 D9930 D9931 D9940 D9951 D9952

Palliative (emergency) treatment of dental pain, minor procedure Fixed partial denture sectioning Evaluation for deep sedation or general anesthesia Deep sedation/general anesthesia, first 30 minutes Deep sedation/general anesthesia, each additional 15 minutes Intravenous moderate (conscious) sedation/analgesia, first 30 minutes Intravenous moderate (conscious) sedation/analgesia, each additional 15 minutes Consultation, diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit for observation (during regularly scheduled hours), no other services performed Office visit, after regularly scheduled hours Treatment of complications (post-surgical), unusual circumstances, by report Cleaning and inspection of a removable appliance Occlusal guard, by report Occlusal adjustment, limited Occlusal adjustment, complete

100% 50% 80% 80% 80% 80% 80% 100% 100% 100% 100% 80% 80% 80% 80%

100% EME* 50% EME* 80% EME* 80% EME* 80% EME* 80% EME* 80% EME* 100% EME* 100% EME* 100% EME* 100% EME* 80% EME* 80% EME* 80% EME* 80% EME*

ADJUNCTIVE GENERAL SERVICES

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

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LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME CODE

DESCRIPTION OF SERVICES

ORTHODONTIC SERVICES

D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8690 D8693 D8694

In Network

Out Of Network

Primary Dentition: Teeth developed and erupted first in order of time. Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines are in the process of shedding and the permanent successors are emerging. Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth that would affect orthodontic treatment. Adult Dentition: The dentition that is present after the cessation of growth that would affect orthodontic treatment. Limited Orthodontic Treatment 50% 50% EME* Limited orthodontic treatment of the primary dentition 50% 50% EME* Limited orthodontic treatment of the transitional dentition 50% 50% EME* Limited orthodontic treatment of the adolescent dentition 50% 50% EME* Limited orthodontic treatment of the adult dentition Interceptive Orthodontic Treatment 50% 50% EME* Interceptive orthodontic treatment of the primary dentition 50% 50% EME* Interceptive orthodontic treatment of the transitional dentition Comprehensive Orthodontic Treatment 50% 50% EME* Comprehensive orthodontic treatment of the transitional dentition 50% 50% EME* Comprehensive orthodontic treatment of the adolescent dentition 50% 50% EME* Comprehensive orthodontic treatment of the adult dentition Minor Treatment to Control Harmful Habits 50% 50% EME* Removable appliance therapy 50% 50% EME* Fixed appliance therapy Other Orthodontic Services 50% 50% EME* Pre-orthodontic treatment examination to monitor growth and development 50% 50% EME* Periodic orthodontic treatment visit 50% 50% EME* Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 50% 50% EME* Orthodontic treatment (alternative billing to a contract fee) 50% 50% EME* Re-cement or re-bond fixed retainer Repair of fixed retainers, includes reattachment 50% 50% EME*

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

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LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME

Limitations: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Two (2) oral examinations (D0120, D0145, D0150, D0180) per calendar year. One (1) full mouth series of x-rays or panoramic film every thirty-six (36) months. Two (2) series of bitewing x-rays per calendar year. Routine bitewing x-rays are limited to eight (8) films per calendar year. Two (2) prophylaxis or periodontal maintenance procedures per calendar year. One (1) fluoride treatment per calendar year for enrollees under age 19. One (1) sealant per tooth every 36 months. Sealant benefits are available only to enrollees under the age of 16. Limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface intact. One (1) crown, pontic, or abutment crown per tooth every five (5) years, and only if dentally necessary. One (1) Gingivectomy/gingivoplasty/gingival flap procedure per quadrant/site every thirty-six (36) months. One (1) osseous surgery per quadrant/site every 60 months One (1) Periodontal scaling & root planing per quadrant/site every twenty-four (24) months. Replacement of full dentures and partial dentures every five (5) years, and only if existing appliance cannot be made serviceable. One (1) denture or partial rebase or reline per appliance every twenty-four (24) months. One (1) tissue conditioning per appliance every twenty-four (24) months. Occlusal guards for bruxism and periodontal disease once every thirty-six (36) months. Space maintainers for covered Dependent children under the age of 19 only to replace primary teeth. General Anesthesia is a covered benefit only when in conjunction with covered oral surgery and pedodontic procedures when dispensed in a dental office by a practitioner acting within the scope of his/her licensure; and when warranted by documented conditions that local anesthetic is contraindicated. General anesthesia, as used for dental pain control, means the elimination of all sensations accompanied by a state of unconsciousness. Patient apprehension and/or nervousness are not of themselves sufficient justification for deep sedation/general anesthesia or intravenous conscious sedation/analgesia.

Orthodontic Limitations: 1. 2. 3. 4.

The Plan will not make any payment for repair or replacement of an orthodontic appliance furnished, in whole or in part, under this program. Orthodontic benefits are limited to dependent enrollee children under age 19. X-rays or extractions are not subject to the Orthodontic maximum. Surgical procedures are not subject to the Orthodontic maximum.

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

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LIBERTY Dental Plan – Making members shine, one smile at a time™

Choice Dental for MGM Resorts Direct Care Health Plan and MGM Resorts Health Plan (PPO) members Calendar Year Deductible: The Calendar year deductible is $50 for individuals to a maximum of $150 for the family. Deductible is waived on Diagnostic and Preventive services. Calendar Year Maximum: $1,500. Orthodontic Lifetime Maximum: $1,000. Available only for dependent enrollee children under age 19. * EME: Eligible Medical Expense, or "allowable charges". Member pays amount above allowable charge or EME

Exclusions: 1. 2. 3.

4.

5.

6. 7. 8. 9. 10. 11. 12. 13. 14.

Topical application of fluoride for anyone over the age of nineteen (19). Sealant benefits for anyone over the age of sixteen (16). Services for injuries or conditions which are compensable under workers' compensation or employers' liability laws; services which are provided to the enrollee by any federal or state government agency or are provided without cost to the enrollee by any municipality, county or other political subdivision except as such exclusion may be prohibited by law. Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those services provided to newborn children for congenital defect or birth abnormalities or services that may be provided under Orthodontic Benefits. Services for restoring tooth structure lost from wear, erosion or abrasion, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion or for stabilizing the teeth. Such services include, but are not limited to, equilibration, periodontal splinting and occlusal adjustment. Any single procedure started prior to the date the person became covered for such services under this program. Prescribed drugs, medication or analgesia. Experimental procedures. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility. Charges for anesthesia, other than by a licensed Dentist for administering general anesthesia in connection with covered oral surgery services. Extraoral grafts (grafting of tissues from outside the mouth to oral tissues. Services with respect to any disturbance of the temporomandibular joint (jaw joint). Services performed by any person other than a Dentist or auxiliary personnel legally authorized to perform services under the direct supervision of a Dentist. For treatment rendered by a person who ordinarily resides in the primary enrollee's household or who is related to the primary enrollee (or to the primary enrollee's spouse) by blood, marriage or legal adoption.

2015-2016 benefit schedule MGM Resorts International (CDT 2015)-150918

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LIBERTY Dental Plan – Making members shine, one smile at a time™