TRIPLE CHOICE Dental Plan

Transcription

1 TRIPLE CHOICE Dental Plan Employee Enrollment Packet (ADP/CDP/Delta) Beta Health Association, Inc. Dental Plan Specialists since or (Corporate Office)

2 Beta Health Association, Inc. Dental Plan Specialists Since 1990 WHAT IS THE TRIPLE CHOICE DENTAL PLAN? The Triple Choice Dental Plan allows each employee the choice of enrolling in the Alpha Dental Plan (ADP), Choice Dental Plan (CDP) or the Delta Dental Insurance Plan. There are over 650 contracted providers in Colorado who participate in either the Alpha or Choice Dental Plan. There are many advantages to this flexible arrangement. Triple Choice Option #1 Option #2 Option #3 Alpha Dental (ADP) Network Plan Discount, fee-for-service Choice Dental (CDP) Network Plan Discount, fee-for-service Delta Dental Plan See any dentist Indemnity Plan See Network Dentist Only No Deductibles to Satisfy Lower Co-Pays No Claim Forms to Complete Unlimited Services Orthodontics (Child & Adult) No Waiting Periods No Pre-authorizations Cosmetic Dentistry Included Low Monthly Cost Immediate Coverage for all services Save approximately 65% overall See Network Dentist Only No Deductibles to Satisfy Slightly Higher Co-Pays No Claim Forms to Complete Unlimited Services Orthodontics (Child & Adult) No Waiting Periods No Pre-authorizations Cosmetic Dentistry Included Low Monthly Cost Immediate Coverage for all Services Save approximately 48% overall Select Any Dentist Deductibles to satisfy $1,000 calendar year max. Waiting periods may apply Takeover credit also available Orthodontics (if available) Cosmetic dentistry included Higher monthly cost

3 Beta Health Association, Inc. Dental Plan Specialists Since 1990 Option #1 and #2 Plan Highlights Cosmetic Dentistry Included No Waiting Periods on any services Orthodontics (braces) covered for Children and Adults No Deductibles to satisfy No Claim Forms to complete No Age limits for members No Limit on Visits No Exclusions for Pre-Existing Conditions No Yearly Maximum Benefit Level (Use as much as you like each year) Guaranteed Acceptance The following fee schedule represents the prenegotiated discounts we have been arranged in advance with the General Dentists who are participating in the plan. Simply pay these amounts directly to your participating dentist at the time services are rendered it s that easy! There are no claim forms to complete.

4 Beta Health Association, Inc. Dental Fee Schedule Alpha Plan #19 Form 7109 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE ALPHA PLAN #19 YOU SAVE Diagnostic Services (Exams and X-rays) 999 ROUTINE OFFICE VISIT $ 35 $ 5 86% 120 PERIODIC ORAL EVALUATION $ 53 NO COST 100% 140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 79 $ 15 81% 150 COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT $ 97 $ 12 88% 210 X-RAY INTRAORAL COMPLETE SERIES INC. BITEWINGS $ 134 $ 29 78% 220 X-RAY INTRAORAL-PERIAPICAL-FIRST FILM $ 31 $ 6 81% 230 X-RAY INTRAORAL PERIAPICAL EACH ADDITIONAL FILM $ 26 $ 5 81% 240 X-RAY INTRA ORAL-OCCLUSAL FILM $ 48 $ 5 90% 250 X-RAY EXTRAORAL-FIRST FILM $ 75 $ 5 93% 260 X-RAY EXTRAORAL-EACH ADDITIONAL FILM $ 63 $ 5 92% 270 X-RAY BITEWING-SINGLE FILM $ 31 NO COST 100% 272 X-RAY BITEWING-2 FILMS $ 48 NO COST 100% 274 X-RAY BITEWING-4 FILMS $ 68 NO COST 100% 330 X-RAY PANORAMIC FILM $ 116 $ 49 58% 340 CEPHALOMETRIC FILM $ 137 $ 60 56% 460 PULP VITALITY TEST $ 61 NO COST 100% 470 DIAGNOSTIC CASTS $ 122 $ 49 60% 999 EMERGENCY VISIT (SAME DAY) $ 90 $ 25 72% Preventive Services (Cleanings) 1110 PROPHYLAXIS-ADULT CLEANING (EVERY 6 MONTHS) $ 96 $ 15 84% 1120 PROPHYLAXIS-CHILD CLEANING (EVERY 6 MONTHS) $ 72 $ 15 79% 1203 TOPICAL APPLICATION OF FLUORIDE NOT INCL/PROPHY-CHILD $ 39 $ 11 72% 1330 ORAL HYGIENE INSTRUCTIONS $ 63 NO COST 100% 1351 SEALANT PER TOOTH $ 58 $ 12 79% 1510 SPACE MAINTAINER FIXED UNILATERAL $ 338 $ % 1515 SPACE MAINTAINER FIXED BILATERAL $ 461 $ % 1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $ 418 $ % 1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $ 522 $ % 1550 RE-CEMENTATION OF SPACE MAINTAINER $ 90 $ 17 81% 1999 ADDITIONAL PROPHY (FOR PERIO MAINTENANCE) $ 96 $ 41 57% Restorative Services (Fillings, Crowns, Inlays and Onlays) 2140 AMALGAM-1 SURFACE (PRIMARY OR PERMANENT) $ 150 $ 33 78% 2150 AMALGAM-2 SURFACES (PRIMARY OR PERMANENT) $ 195 $ 44 77% 2160 AMALGAM-3 SURFACES (PRIMARY OR PERMANENT) $ 232 $ 54 77% 2161 AMALGAM-4 OR MORE SURFACES (PRIMARY OR PERMANENT) $ 272 $ 63 77% 2330 RESIN BASED COMPOSITE 1 SURFACE (ANTERIOR) $ 169 $ 45 73% 2331 RESIN BASED COMPOSITE 2 SURFACES (ANTERIOR) $ 212 $ 58 73% 2332 RESIN BASED COMPOSITE 3 SURFACES (ANTERIOR) $ 264 $ 77 71% 2335 RESIN 4 OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $ 328 $ % 2390 RESIN BASED COMPOSITE CROWN ( ANTERIOR) $ 476 $ % 2391 RESIN BASED COMPOSITE ONE SURFACE (POSTERIOR) $ 188 $ 98 48% 2392 RESIN BASED COMPOSITE TWO SURFACE (POSTERIOR) $ 243 $ % 2393 RESIN BASED COMPOSITE THREE SURFACE (POSTERIOR) $ 305 $ % 2394 RESIN BASED COMPOSITE FOUR OR MORE SURFACES (POSTERIOR) $ 364 $ % *2510 INLAY-METALLIC-ONE SURFACE $ 906 $ % *2520 INLAY-METALLIC-TWO SURFACE $ 936 $ % *2530 INLAY-METALLIC-THREE OR MORE SURFACES $ 991 $ % *2542 ONLAY-METALLIC-TWO SURFACES $ 1,005 $ % *2543 ONLAY-METALLIC-THREE SURFACES $ 1,037 $ % *2544 ONLAY-METALLIC-FOUR OR MORE SURFACES $ 1,069 $ % *2610 INLAY-PORCELAIN/CERAMIC-ONE SURFACE $ 965 $ % *2650 INLAY-RESIN BASED COMPOSITE-ONE SURFACE $ 927 $ % *2651 INLAY-RESIN BASED COMPOSITE-TWO SURFACES $ 952 $ % *2652 INLAY-RESIN BASED COMPOSITE-THREE OR MORE SURFACES $ 993 $ % *2710 CROWN-RESIN BASED COMPOSITE (INDIRECT) $ 963 $ % *2720 CROWN-RESIN WITH HIGH NOBLE METAL $ 1,139 $ % *2721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $ 1,032 $ % *2722 CROWN RESIN WITH NOBLE METAL $ 1,048 $ % *2740 CROWN PORCELAIN/CERAMIC SUBSTRATE $ 1,196 $ % *2750 CROWN PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,164 $ % *2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,054 $ % *2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $ 1,091 $ % Current Dental Terminology American Dental Association Page 1

5 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE ALPHA PLAN #19 YOU SAVE Restorative Services (Fillings, Crowns, Inlays and Onlays) Con't *2790 CROWN FULL CAST HIGH NOBLE METAL $ 1,154 $ % *2791 CROWN FULL CAST PREDOMINANTLY BASE METAL $ 1,028 $ % *2792 CROWN FULL CAST NOBLE METAL $ 1,058 $ % 2910 RECEMENT INLAY, ONLAY, OR PARTIAL COVERAGE RESTORATION $ 116 $ 15 87% 2920 RECEMENT CROWN $ 116 $ 31 73% 2930 PREFAB. STAINLESS STEEL CROWN-PRIMARY $ 291 $ % 2931 PREFAB STAINLESS STEEL CROWN-PERMANENT $ 355 $ % 2932 PREFAB. RESIN CROWN $ 376 $ % 2933 PREFAB. STAINLESS STEEL CROWN WITH RESIN WINDOW $ 398 $ % 2940 SEDATIVE FILLING $ 132 $ 37 72% 2950 CORE BUILDUP INCLUDING ANY PINS $ 292 $ 82 72% 2951 PIN RETENTION PER TOOTH IN ADD. TO RESTORATION $ 81 $ 23 72% 2952 CAST POST & CORE IN ADDITION TO CROWN $ 456 $ % 2954 PREFAB POST & CORE IN ADDITION TO CROWN $ 365 $ % 2955 POST REMOVAL (NOT IN CONJUNCTION WITH ENDODONTIC THERAPY) $ 317 $ % 2960 LABIAL VENEER RESIN LAMINATE (CHAIRSIDE) $ 714 $ % 2999 BLEACHING (PER ARCH) $ 270 $ % 2999 $125 ADDTL.CHARGE P/UNIT FOR MULTIPLE CROWN UNITS/COMPLEX REHABILITATION *These co-payments do not include an allowable $151 lab fee (per unit). Doctors, please make sure that all members understand what their fees will be and what the savings are from your Usual and Customary fees. Temporary crowns are included with permanent crown preparation. Endodontic Services (Root Canals) 3110 PULP CAP DIRECT EXCLUDING FINAL RESTORATION $ 90 $ 26 71% 3120 PULP CAP INDIRECT EXCLUDING FINAL RESTORATION $ 93 $ 27 71% 3220 THERAPEUTIC PULPOTOMY EXCLUDING FINAL RESTORATION $ 218 $ 72 67% 3230 PULPAL THERAPY ANTERIOR, PRIMARY TOOTH EXCLUDING REST. $ 328 $ % 3240 PULPAL THERAPY POSTERIOR, PRIMARY TOOTH EXCLUDING REST $ 370 $ % 3310 ROOT CANAL THERAPY 1 CANAL (EXCLUDING FINAL RESTORATION) $ 778 $ % 3320 ROOT CANAL THERAPY 2 CANALS (EXCLUDING FINAL RESTORATION) $ 874 $ % 3330 ROOT CANAL THERAPY 3 CANALS OR MORE $ 1,058 $ % 3410 APICOECTOMY/PERIRADICULAR SURGERY-ANTERIOR $ 741 $ % 3421 APICOECTOMY/PERIRADICULAR SURGERY-BICUSPID (FIRST ROOT) $ 805 $ % 3425 APICOECTOMY/PERIRADICULAR SURGERY-MOLAR (FIRST ROOT) $ 950 $ % 3426 APICOECTOMY/PERIRADICULAR SURGERY-EACH ADDITIONAL ROOT $ 450 $ % 3430 RETROGRADE FILLING-PER ROOT $ 315 $ % 3910 SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM $ 279 $ 64 77% Periodontic Services (Gum Disease) 4210 GINGIVOPLASY OR GIGIVECTOMY- 4+ CONTIGUOUS OR BOUNDED SP. TEETH P/QUAD $ 704 $ % 4211 GINGIVECTOMY OR GINGIVOPLASTY-1 TO 3 CONTIGUOUS OR BOUNDED SP. TEETH P/QUAD $ 323 $ % 4240 GINGIVAL FLAP PROCEDURE, INCL.ROOT PLNG -4+ CONTIG. OR BOUNDED SP. TEETH P/QUAD $ 820 $ % 4260 OSSEOUS SURG. INCL. FLAP ENTRY & CLOSURE-4+ CONTIG. OR BOUNDED SP. TEETH P/QUAD $ 1,138 $ % 4320 PROVISIONAL SPLINTING-INTRACORNIAL $ 556 $ % 4321 PROVISIONAL SPLINTING-EXTRACORNIAL $ 527 $ % 4341 PERIODONTAL SCALING & ROOT PLNG- 4+ TEETH PER QUAD $ 265 $ % 4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMP.EVAL. & DIAGNOSIS $ 197 $ 89 55% 4910 PERIODONTAL MAINTENANCE $ 146 $ 57 61% 4999 PERIO SCREENING AND SCORING $ 30 $ 10 67% Prosthodontics (Removable/Complete Dentures, etc.) 5110 COMPLETE DENTURE-MAXILLARY $ 1,799 $ % 5120 COMPLETE DENTURE-MANDIBULAR $ 1,799 $ % 5130 IMMEDIATE DENTURE-MAXILLARY $ 1,921 $ % 5140 IMMEDIATE DENTURE-MANDIBULAR $ 1,958 $ % 5211 MAXILLARY PART. DENTURE-RESIN BASE (INCL. CLASPS & TEETH) $ 1,474 $ % 5212 MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCL. CLASPS & TEETH) $ 1,448 $ % 5213 MAXILLARY PART. DENT.-CST MTL FRMEWRK W/RESIN DENT. BASE (INCL/CLASPS & TEETH) $ 1,885 $ % 5214 MANDIBULAR PART. DENT.-CST MTL FRMEWRK W/RESIN DENT. BASE (INCL/CLASPS & TEETH) $ 1,889 $ % 5410 ADJUST COMPLETE DENTURE-MAXILLARY $ 96 $ 36 63% 5411 ADJUST COMPLETE DENTURE-MANDIBULAR $ 95 $ 36 62% 5421 ADJUST PARTIAL DENTURE-MAXILLARY $ 95 $ 36 62% 5422 ADJUST PARTIAL DENTURE-MANDIBULAR $ 95 $ 36 62% 5510 REPAIR BROKEN COMPLETE DENTURE BASE $ 231 $ 88 62% 5520 REPLACE MISSING OF BROKEN TEETH-COMP.DENTURE-EACH TOOTH $ 197 $ 62 69% 5610 REPAIR RESIN DENTURE BASE $ 225 $ 82 64% 5620 REPAIR CAST FRAMEWORK $ 313 $ % 5630 REPAIR OR REPLACE BROKEN CLASP $ 286 $ % 5640 REPLACE BROKEN TEETH-PER TOOTH $ 198 $ 68 66% 5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $ 241 $ 93 61% 5660 ADD CLASP TO EXISTING PARTIAL DENTURE $ 292 $ % Current Dental Terminology American Dental Association Page 2

6 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE ALPHA PLAN #19 YOU SAVE Prosthodontics (Removable/ Complete Dentures, etc.) Con't 5710 REBASE COMPLETE MAXILLARY DENTURE $ 630 $ % 5711 REBASE COMPLETE MANDIBULAR DENTURE $ 629 $ % 5720 REBASE MAXILLARY PARTIAL DENTURE $ 609 $ % 5721 REBASE MANDIBULAR PARTIAL DENTURE $ 609 $ % 5730 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ 402 $ % 5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ 402 $ % 5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $ 397 $ % 5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) $ 402 $ % 5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) $ 503 $ % 5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) $ 503 $ % 5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) $ 503 $ % 5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $ 503 $ % 5850 TISSUE CONDITIONING MAXILLARY $ 231 $ 66 71% 5851 TISSUE CONDITIONING MANDIBULAR $ 233 $ 65 72% NOTE: In addition to the fees listed above in section 5000 thru 6000, additional fees may be charged for upgraded teeth and enhanced cosmetics, personalization beyond norm or techniques involving precision dentures. Prosthodontics (fixed/partial Dentures, etc.) *6210 PONTIC-CAST HIGH NOBLE METAL $ 1,133 $ % *6211 PONTIC-CAST PREDOMINANTLY BASE METAL $ 1,037 $ % *6212 PONTIC-CAST NOBLE METAL $ 1,075 $ % *6240 PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,161 $ % *6241 PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,058 $ % *6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL $ 1,084 $ % *6250 PONTIC-RESIN WITH HIGH NOBLE METAL $ 1,085 $ % *6251 PONTIC-RESIN WITH PREDOMINANTLY BASE METAL $ 1,042 $ % *6252 PONTIC-RESIN WITH NOBLE METAL $ 1,044 $ % *6720 CROWN-RESIN WITH HIGH NOBLE METAL $ 1,154 $ % *6721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $ 1,042 $ % *6722 CROWN-RESIN WITH NOBLE METAL $ 1,067 $ % *6750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,164 $ % *6751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,052 $ % *6752 CROWN-PORCELAIN FUSED TO NOBLE METAL $ 1,079 $ % *6790 CROWN-FULL CAST HIGH NOBLE METAL $ 1,133 $ % *6791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $ 1,042 $ % *6792 CROWN-FULL CAST NOBLE METAL $ 1,084 $ % 6930 RECEMENT FIXED PARTIAL DENTURE $ 185 $ 69 63% *These co-payments do not include an allowable $151 lab fee (per unit). Doctors, please make sure that all members understand what their fees will be and what the savings are from your Usual and Customary fee. Oral Surgery (Extractions, etc.) 7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) $ 185 $ 46 75% 7210 SURGICAL EXT. ERUPTED TOOTH WITH REMOVAL OF BONE $ 295 $ 81 73% 7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $ 345 $ 92 73% 7230 REMOVAL OF IMPACTED TOOTH PARTIALLY BONY $ 419 $ % 7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $ 524 $ % 7241 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY W/ UNUSUAL SURG. COMPLICATION $ 635 $ % 7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $ 322 $ % 7270 TOOTH REIMPL. AND/OR STAB. OF ACC.EVULSED OR DISPL. TOOTH $ 609 $ % 7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $ 540 $ % 7285 BIOPSY OF ORAL TISSUE-HARD (BONE-TOOTH) $ 497 $ % 7286 BIOPSY OF ORAL TISSUE-SOFT $ 344 $ % 7310 ALVEOPLASTY IN CONJ. WITH EXT.- PER QUAD $ 329 $ % 7320 ALVEOPLASTY NOT IN CONJ WITH EXT- PER QUAD $ 528 $ % 7510 INCISION AND DRAINAGE ABSCESS- INTRAORAL SOFT TISSUE $ 255 $ 99 61% 7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5CM $ 341 NO COST 100% 7960 FRENULECTOMY (FRENECTOMY OR FRENOTOMY)- SEPARATE PROCEDURE $ 498 $ % 7970 EXCISION OF HYPERPLASTIC TISSUE- PER ARCH $ 582 $ % General Miscellaneous Services 9110 EMERGENCY PALATIVE TREATMENT OF DENTAL PAIN- MINOR PROCEDURE $ 138 $ 48 65% 9230 ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE - FIRST 30 MINUTES $ 95 $ 27 72% 9310 CONSULTATION (DIAG. SERV. PROV. BY DENTIST OR PHYSICIAN OTHER THAN PRACTIONER PROV. TREATMNT) $ 159 NO COST 100% 9910 APPLICATION OF DESENSITIZING MEDICAMENT $ 73 $ 6 92% 9941 FABRICATION OF ATHLETIC MOUTHGUARD $ 315 $ % 9951 OCCLUSAL ADJUSTMENT-LIMITED $ 212 $ 77 64% 9952 OCCLUSAL ADJUSTMENT-COMPLETE $ 770 $ % 9999 MISSED APPOINTMENT (WITHOUT 24 HOUR NOTICE) $ 54 $ 30 44% Current Dental Terminology American Dental Association Page 3

7 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE ALPHA PLAN #19 YOU SAVE Orthodontics (Braces) for Children & Adults Monthly Payment 13 MONTH TREATMENT PLAN ($137/MONTH) $ 3,114 $ 2,409 23% 16 MONTH TREATMENT PLAN ($137/MONTH) $ 3,625 $ 2,820 22% 19 MONTH TREATMENT PLAN ($137/MONTH) $ 4,135 $ 3,231 22% 22 MONTH TREATMENT PLAN ($137/MONTH) $ 4,606 $ 3,642 21% 25 MONTH TREATMENT PLAN ($137/MONTH) $ 5,158 $ 4,053 21% 28 MONTH TREATMENT PLAN ($137/MONTH) $ 5,669 $ 4,464 21% 31 MONTH TREATMENT PLAN ($137/MONTH) $ 6,179 $ 4,875 21% 34 MONTH TREATMENT PLAN ($137/MONTH) $ 6,690 $ 5,286 21% 36 MONTH TREATMENT PLAN ($137/MONTH) $ 6,951 $ 5,560 20% Other Orthodontic Guidelines 1. A $382 charge will apply at the end of treatment (included in the above amounts) to cover all retention office visits (unlimited). 2. Services not listed above will be discounted 30% off of the participating Orthodontist's Usual and Customary fees (except #5 listed below). 3. Services must only be provided by a contracted Orthodontic Specialist. 4. The amounts listed above also include an initial one-time $246 charge for all records, mold, x-rays, etc. to determine the Orthodontic Treatment for the patient. 5. Invisalign procedures are to be discounted 15% off the participating Orthodontist's Usual and Customary fees. All Plans General Limitations and Exclusions 1. All fees listed above do not include all appropriate lab fees. Member must agree (in writing) to all upgraded materials before treatment is started. See each section for specific details (if applicable). 2. All patients are responsible for paying all fees (as listed above) at the time services are rendered. 3. These fees are for General Dentists only. A participating specialist list is available by calling our office at or Any procedures not listed will be discounted 20% off the participating General Dentists normal fees. 5. Medical costs associated with any dental procedures are not covered. 6. Dentures or appliances will be replaced only after 3 years have elapsed since such dentures or appliances were provided under any plan program, unless the denture or appliance becomes unserviceable due to illness or other causes not controlled by other means. Replacement of dentures, appliances, or bridgework due to loss or theft are not covered. 7. Any dental treatment started prior to the Member's eligibility to receive services under this plan or started after a Member's termination are not covered. 8. Failure to follow the prescribed treatment or accidents occurring during the course of treatment may result in additional charges by your plan provider. 9. Failure to pay scheduled fees at the time service is rendered may prevent future dental services from being received until all fees have been paid in full. 10. Services provided by non-participating dentists are not covered. 11. Services which, in the opinion of the attending dentist, are not necessary for the patient's dental health, or are contrary to established dental ethics are not covered. 12. Cosmetic dental procedures are covered only if the attending dentist and patient agree on the specific procedure. 13. Services which are compensable under Worker's Compensation or employer liability laws are not covered. 14. General anesthesia and IV sedation are not covered. 15. Myofunctional therapy procedure for training, treating or developing muscles in and around the jaw or mouth including TMJ are not covered except by participating plan specialists. 16. Any dental procedure or service that cannot be performed in the dental office due to general and/or physical limitations of a member are not covered. 17. Expenses incurred for dental procedures initiated prior to member's eligibility or after termination are not covered. 18. Any services that the Participating General Dentist recommends be performed by a specialist are covered only by a plan participating specialist. 19. The liability of Beta Health Association, Inc. is limited to the return of the membership fees paid for one year by the member. 20. Extractions for asymptomatic third molars (wisdom teeth) are not covered unless causing movement of the teeth. An example of symptomatic include severe decay, and ontogenic cysts, chronic pericoronitis, and infection. 21. The Beta Health Association, Inc. dental programs do not constitute dental insurance and are considered discount, fee-forservice dental plans. 22. Fees are subject to change on an as needed basis. Please contact Beta Health Association, Inc. for current fees. Current Dental Terminology American Dental Association Page 4

8 Beta Health Association, Inc. Dental Fee Schedule Choice Plan #20 Form 7109 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE CHOICE PLAN #20 YOU SAVE Diagnostic Services (Exams and X-rays) 999 ROUTINE OFFICE VISIT $ 35 $ 5 86% 120 PERIODIC ORAL EVALUATION $ 53 $ 28 47% 140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 79 $ 43 46% 150 COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT $ 97 $ 45 54% 210 X-RAY INTRAORAL COMPLETE SERIES INC. BITEWINGS $ 134 $ 80 40% 220 X-RAY INTRAORAL-PERIAPICAL-FIRST FILM $ 31 $ 16 48% 230 X-RAY INTRAORAL PERIAPICAL EACH ADDITIONAL FILM $ 26 $ 14 46% 240 X-RAY INTRA ORAL-OCCLUSAL FILM $ 48 $ 23 52% 250 X-RAY EXTRAORAL-FIRST FILM $ 75 $ 32 57% 260 X-RAY EXTRAORAL-EACH ADDITIONAL FILM $ 63 $ 19 70% 270 X-RAY BITEWING-SINGLE FILM $ 31 $ 13 58% 272 X-RAY BITEWING-2 FILMS $ 48 $ 29 40% 274 X-RAY BITEWING-4 FILMS $ 68 $ 39 43% 330 X-RAY PANORAMIC FILM $ 116 $ 66 43% 340 CEPHALOMETRIC FILM $ 137 $ 58 58% 460 PULP VITALITY TEST $ 61 $ 31 49% 470 DIAGNOSTIC CASTS $ 122 $ 68 44% 999 EMERGENCY VISIT (SAME DAY) $ 90 $ 65 28% Preventive Services (Cleanings) 1110 PROPHYLAXIS-ADULT CLEANING (EVERY 6 MONTHS) $ 96 $ 61 36% 1120 PROPHYLAXIS-CHILD CLEANING (EVERY 6 MONTHS) $ 72 $ 43 40% 1203 TOPICAL APPLICATION OF FLUORIDE NOT INCL/PROPHY-CHILD $ 39 $ 21 46% 1330 ORAL HYGIENE INSTRUCTIONS $ 63 $ 26 59% 1351 SEALANT PER TOOTH $ 58 $ 34 41% 1510 SPACE MAINTAINER FIXED UNILATERAL $ 338 $ % 1515 SPACE MAINTAINER FIXED BILATERAL $ 461 $ % 1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $ 418 $ % 1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $ 522 $ % 1550 RE-CEMENTATION OF SPACE MAINTAINER $ 90 $ 42 53% 1999 ADDITIONAL PROPHY (FOR PERIO MAINTENANCE) $ 96 $ 61 36% Restorative Services (Fillings, Crowns, Inlays and Onlays) 2140 AMALGAM-1 SURFACE (PRIMARY OR PERMANENT) $ 150 $ 97 35% 2150 AMALGAM-2 SURFACES (PRIMARY OR PERMANENT) $ 195 $ % 2160 AMALGAM-3 SURFACES (PRIMARY OR PERMANENT) $ 232 $ % 2161 AMALGAM-4 OR MORE SURFACES (PRIMARY OR PERMANENT) $ 272 $ % 2330 RESIN BASED COMPOSITE 1 SURFACE (ANTERIOR) $ 169 $ 99 41% 2331 RESIN BASED COMPOSITE 2 SURFACES (ANTERIOR) $ 212 $ % 2332 RESIN BASED COMPOSITE 3 SURFACES (ANTERIOR) $ 264 $ % 2335 RESIN 4 OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $ 328 $ % 2390 RESIN BASED COMPOSITE CROWN ( ANTERIOR) $ 476 $ % 2391 RESIN BASED COMPOSITE ONE SURFACE (POSTERIOR) $ 188 $ % 2392 RESIN BASED COMPOSITE TWO SURFACE (POSTERIOR) $ 243 $ % 2393 RESIN BASED COMPOSITE THREE SURFACE (POSTERIOR) $ 305 $ % 2394 RESIN BASED COMPOSITE FOUR OR MORE SURFACES (POSTERIOR) $ 364 $ % 2510 INLAY-METALLIC-ONE SURFACE $ 906 $ % 2520 INLAY-METALLIC-TWO SURFACE $ 936 $ % 2530 INLAY-METALLIC-THREE OR MORE SURFACES $ 991 $ % 2542 ONLAY-METALLIC-TWO SURFACES $ 1,005 $ % 2543 ONLAY-METALLIC-THREE SURFACES $ 1,037 $ % 2544 ONLAY-METALLIC-FOUR OR MORE SURFACES $ 1,069 $ % 2610 INLAY-PORCELAIN/CERAMIC-ONE SURFACE $ 965 $ % 2650 INLAY-RESIN BASED COMPOSITE-ONE SURFACE $ 927 $ % 2651 INLAY-RESIN BASED COMPOSITE-TWO SURFACES $ 952 $ % 2652 INLAY-RESIN BASED COMPOSITE-THREE OR MORE SURFACES $ 993 $ % 2710 CROWN-RESIN BASED COMPOSITE (INDIRECT) $ 963 $ % 2720 CROWN-RESIN WITH HIGH NOBLE METAL $ 1,139 $ % 2721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $ 1,032 $ % 2722 CROWN RESIN WITH NOBLE METAL $ 1,048 $ % 2740 CROWN PORCELAIN/CERAMIC SUBSTRATE $ 1,196 $ % 2750 CROWN PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,164 $ % 2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,054 $ % 2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $ 1,091 $ % Current Dental Terminology American Dental Association Page 1

9 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE CHOICE PLAN #20 YOU SAVE Restorative Services (Fillings, Crowns, Inlays and Onlays) Con't 2790 CROWN FULL CAST HIGH NOBLE METAL $ 1,154 $ % 2791 CROWN FULL CAST PREDOMINANTLY BASE METAL $ 1,028 $ % 2792 CROWN FULL CAST NOBLE METAL $ 1,058 $ % 2910 RECEMENT INLAY, ONLAY, OR PARTIAL COVERAGE RESTORATION $ 116 $ 50 57% 2920 RECEMENT CROWN $ 116 $ 59 49% 2930 PREFAB. STAINLESS STEEL CROWN-PRIMARY $ 291 $ % 2931 PREFAB STAINLESS STEEL CROWN-PERMANENT $ 355 $ % 2932 PREFAB. RESIN CROWN $ 376 $ % 2933 PREFAB. STAINLESS STEEL CROWN WITH RESIN WINDOW $ 398 $ % 2940 SEDATIVE FILLING $ 132 $ 67 49% 2950 CORE BUILDUP INCLUDING ANY PINS $ 292 $ % 2951 PIN RETENTION PER TOOTH IN ADD. TO RESTORATION $ 81 $ 37 54% 2952 CAST POST & CORE IN ADDITION TO CROWN $ 456 $ % 2954 PREFAB POST & CORE IN ADDITION TO CROWN $ 365 $ % 2955 POST REMOVAL (NOT IN CONJUNCTION WITH ENDODONTIC THERAPY) $ 317 $ % 2960 LABIAL VENEER RESIN LAMINATE (CHAIRSIDE) $ 714 $ % 2999 BLEACHING (PER ARCH) $ 270 $ % 2999 $125 ADDTL.CHARGE P/UNIT FOR MULTIPLE CROWN UNITS/COMPLEX REHABILITATION Doctors, please make sure that all members understand what their fees will be and what the savings are from your Usual and Customary fees. Temporary crowns are included with permanent crown preparation. Endodontic Services (Root Canals) 3110 PULP CAP DIRECT EXCLUDING FINAL RESTORATION $ 90 $ 36 60% 3120 PULP CAP INDIRECT EXCLUDING FINAL RESTORATION $ 93 $ 47 49% 3220 THERAPEUTIC PULPOTOMY EXCLUDING FINAL RESTORATION $ 218 $ % 3230 PULPAL THERAPY ANTERIOR, PRIMARY TOOTH EXCLUDING REST. $ 328 $ % 3240 PULPAL THERAPY POSTERIOR, PRIMARY TOOTH EXCLUDING REST $ 370 $ % 3310 ROOT CANAL THERAPY 1 CANAL (EXCLUDING FINAL RESTORATION) $ 778 $ % 3320 ROOT CANAL THERAPY 2 CANALS (EXCLUDING FINAL RESTORATION) $ 874 $ % 3330 ROOT CANAL THERAPY 3 CANALS OR MORE $ 1,058 $ % 3410 APICOECTOMY/PERIRADICULAR SURGERY-ANTERIOR $ 741 $ % 3421 APICOECTOMY/PERIRADICULAR SURGERY-BICUSPID (FIRST ROOT) $ 805 $ % 3425 APICOECTOMY/PERIRADICULAR SURGERY-MOLAR (FIRST ROOT) $ 950 $ % 3426 APICOECTOMY/PERIRADICULAR SURGERY-EACH ADDITIONAL ROOT $ 450 $ % 3430 RETROGRADE FILLING-PER ROOT $ 315 $ % 3910 SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM $ 279 $ % Periodontic Services (Gum Disease) 4210 GINGIVOPLASY OR GIGIVECTOMY- 4+ CONTIGUOUS OR BOUNDED SP. TEETH P/QUAD $ 704 $ % 4211 GINGIVECTOMY OR GINGIVOPLASTY-1 TO 3 CONTIGUOUS OR BOUNDED SP. TEETH P/QUAD $ 323 $ 95 71% 4240 GINGIVAL FLAP PROCEDURE, INCL.ROOT PLNG -4+ CONTIG. OR BOUNDED SP. TEETH P/QUAD $ 820 $ % 4260 OSSEOUS SURG. INCL. FLAP ENTRY & CLOSURE-4+ CONTIG. OR BOUNDED SP. TEETH P/QUAD $ 1,138 $ % 4320 PROVISIONAL SPLINTING-INTRACORNIAL $ 556 $ % 4321 PROVISIONAL SPLINTING-EXTRACORNIAL $ 527 $ % 4341 PERIODONTAL SCALING & ROOT PLNG- 4+ TEETH PER QUAD $ 265 $ % 4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMP.EVAL. & DIAGNOSIS $ 197 $ % 4910 PERIODONTAL MAINTENANCE $ 146 $ 85 42% 4999 PERIO SCREENING AND SCORING $ 30 $ 15 50% Prosthodontics (Removable/Complete Dentures, etc.) 5110 COMPLETE DENTURE-MAXILLARY $ 1,799 $ 1,040 42% 5120 COMPLETE DENTURE-MANDIBULAR $ 1,799 $ 1,002 44% 5130 IMMEDIATE DENTURE-MAXILLARY $ 1,921 $ 1,048 45% 5140 IMMEDIATE DENTURE-MANDIBULAR $ 1,958 $ 1,064 46% 5211 MAXILLARY PART. DENTURE-RESIN BASE (INCL. CLASPS & TEETH) $ 1,474 $ % 5212 MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCL. CLASPS & TEETH) $ 1,448 $ % 5213 MAXILLARY PART. DENT.-CST MTL FRMEWRK W/RESIN DENT. BASE (INCL/CLASPS & TEETH) $ 1,885 $ % 5214 MANDIBULAR PART. DENT.-CST MTL FRMEWRK W/RESIN DENT. BASE (INCL/CLASPS & TEETH) $ 1,889 $ % 5410 ADJUST COMPLETE DENTURE-MAXILLARY $ 96 $ 58 40% 5411 ADJUST COMPLETE DENTURE-MANDIBULAR $ 95 $ 41 57% 5421 ADJUST PARTIAL DENTURE-MAXILLARY $ 95 $ 41 57% 5422 ADJUST PARTIAL DENTURE-MANDIBULAR $ 95 $ 41 57% 5510 REPAIR BROKEN COMPLETE DENTURE BASE $ 231 $ % 5520 REPLACE MISSING OF BROKEN TEETH-COMP.DENTURE-EACH TOOTH $ 197 $ 99 50% 5610 REPAIR RESIN DENTURE BASE $ 225 $ 97 57% 5620 REPAIR CAST FRAMEWORK $ 313 $ % 5630 REPAIR OR REPLACE BROKEN CLASP $ 286 $ % 5640 REPLACE BROKEN TEETH-PER TOOTH $ 198 $ 98 51% 5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $ 241 $ % 5660 ADD CLASP TO EXISTING PARTIAL DENTURE $ 292 $ % Current Dental Terminology American Dental Association Page 2

10 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE CHOICE PLAN #20 YOU SAVE Prosthodontics (Removable/ Complete Dentures, etc.) Con't 5710 REBASE COMPLETE MAXILLARY DENTURE $ 630 $ % 5711 REBASE COMPLETE MANDIBULAR DENTURE $ 629 $ % 5720 REBASE MAXILLARY PARTIAL DENTURE $ 609 $ % 5721 REBASE MANDIBULAR PARTIAL DENTURE $ 609 $ % 5730 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ 402 $ % 5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ 402 $ % 5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $ 397 $ % 5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) $ 402 $ % 5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) $ 503 $ % 5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) $ 503 $ % 5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) $ 503 $ % 5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $ 503 $ % 5850 TISSUE CONDITIONING MAXILLARY $ 231 $ 88 62% 5851 TISSUE CONDITIONING MANDIBULAR $ 233 $ 88 62% NOTE: In addition to the fees listed above in section 5000 thru 6000, additional fees may be charged for upgraded teeth and enhanced cosmetics, personalization beyond norm or techniques involving precision dentures. Prosthodontics (fixed/partialdentures, etc.) 6210 PONTIC-CAST HIGH NOBLE METAL $ 1,133 $ % 6211 PONTIC-CAST PREDOMINANTLY BASE METAL $ 1,037 $ % 6212 PONTIC-CAST NOBLE METAL $ 1,075 $ % 6240 PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,161 $ % 6241 PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,058 $ % 6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL $ 1,084 $ % 6250 PONTIC-RESIN WITH HIGH NOBLE METAL $ 1,085 $ % 6251 PONTIC-RESIN WITH PREDOMINANTLY BASE METAL $ 1,042 $ % 6252 PONTIC-RESIN WITH NOBLE METAL $ 1,044 $ % 6720 CROWN-RESIN WITH HIGH NOBLE METAL $ 1,154 $ % 6721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $ 1,042 $ % 6722 CROWN-RESIN WITH NOBLE METAL $ 1,067 $ % 6750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $ 1,164 $ % 6751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 1,052 $ % 6752 CROWN-PORCELAIN FUSED TO NOBLE METAL $ 1,079 $ % 6790 CROWN-FULL CAST HIGH NOBLE METAL $ 1,133 $ % 6791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $ 1,042 $ % 6792 CROWN-FULL CAST NOBLE METAL $ 1,084 $ % 6930 RECEMENT FIXED PARTIAL DENTURE $ 185 $ 84 55% Doctors, please make sure that all members understand what their fees will be and what the savings are from your Usual and Customary fee. Oral Surgery (Extractions, etc.) 7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) $ 185 $ 90 51% 7210 SURGICAL EXT. ERUPTED TOOTH WITH REMOVAL OF BONE $ 295 $ % 7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $ 345 $ % 7230 REMOVAL OF IMPACTED TOOTH PARTIALLY BONY $ 419 $ % 7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $ 524 $ % 7241 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY W/ UNUSUAL SURG. COMPLICATION $ 635 $ % 7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $ 322 $ % 7270 TOOTH REIMPL. AND/OR STAB. OF ACC.EVULSED OR DISPL. TOOTH $ 609 $ % 7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $ 540 $ % 7285 BIOPSY OF ORAL TISSUE-HARD (BONE-TOOTH) $ 497 $ % 7286 BIOPSY OF ORAL TISSUE-SOFT $ 344 $ % 7310 ALVEOPLASTY IN CONJ. WITH EXT.- PER QUAD $ 329 $ % 7320 ALVEOPLASTY NOT IN CONJ WITH EXT- PER QUAD $ 528 $ % 7510 INCISION AND DRAINAGE ABSCESS- INTRAORAL SOFT TISSUE $ 255 $ % 7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5CM $ 341 $ 87 74% 7960 FRENULECTOMY (FRENECTOMY OR FRENOTOMY)- SEPARATE PROCEDURE $ 498 $ % 7970 EXCISION OF HYPERPLASTIC TISSUE- PER ARCH $ 582 $ % General Miscellaneous Services 9110 EMERGENCY PALATIVE TREATMENT OF DENTAL PAIN- MINOR PROCEDURE $ 138 $ 70 49% 9230 ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE - FIRST 30 MINUTES $ 95 $ 37 61% 9310 CONSULTATION (DIAG. SERV. PROV. BY DENTIST OR PHYSICIAN OTHER THAN PRACTIONER PROV. TREATMNT) $ 159 $ 62 61% 9910 APPLICATION OF DESENSITIZING MEDICAMENT $ 73 $ 43 41% 9941 FABRICATION OF ATHLETIC MOUTHGUARD $ 315 $ 93 70% 9951 OCCLUSAL ADJUSTMENT-LIMITED $ 212 $ % 9952 OCCLUSAL ADJUSTMENT-COMPLETE $ 770 $ % 9999 MISSED APPOINTMENT (WITHOUT 24 HOUR NOTICE) $ 54 $ 35 35% Current Dental Terminology American Dental Association Page 3

11 ADA CODE DENTAL PROCEDURE/ADA CODE DESCRIPTION NORMAL FEE CHOICE PLAN #20 YOU SAVE Orthodontics (Braces) for Children & Adults Monthly Payment 13 MONTH TREATMENT PLAN ($137/MONTH) $ 3,114 $ 2,409 23% 16 MONTH TREATMENT PLAN ($137/MONTH) $ 3,625 $ 2,820 22% 19 MONTH TREATMENT PLAN ($137/MONTH) $ 4,135 $ 3,231 22% 22 MONTH TREATMENT PLAN ($137/MONTH) $ 4,606 $ 3,642 21% 25 MONTH TREATMENT PLAN ($137/MONTH) $ 5,158 $ 4,053 21% 28 MONTH TREATMENT PLAN ($137/MONTH) $ 5,669 $ 4,464 21% 31 MONTH TREATMENT PLAN ($137/MONTH) $ 6,179 $ 4,875 21% 34 MONTH TREATMENT PLAN ($137/MONTH) $ 6,690 $ 5,286 21% 36 MONTH TREATMENT PLAN ($137/MONTH) $ 6,951 $ 5,560 20% Other Orthodontic Guidelines 1. A $382 charge will apply at the end of treatment (included in the above amounts) to cover all retention office visits (unlimited). 2. Services not listed above will be discounted 30% off of the participating Orthodontist's Usual and Customary fees (except #5 listed below). 3. Services must only be provided by a contracted Orthodontic Specialist. 4. The amounts listed above also include an initial one-time $246 charge for all records, mold, x-rays, etc. to determine the Orthodontic Treatment for the patient. 5. Invisalign procedures are to be discounted 15% off the participating Orthodontist's Usual and Customary fees. All Plans General Limitations and Exclusions 1. All fees listed above do not include all appropriate lab fees. Member must agree (in writing) to all upgraded materials before treatment is started. See each section for specific details (if applicable). 2. All patients are responsible for paying all fees (as listed above) at the time services are rendered. 3. These fees are for General Dentists only. A participating specialist list is available by calling our office at or Any procedures not listed will be discounted 20% off the participating General Dentists normal fees. 5. Medical costs associated with any dental procedures are not covered. 6. Dentures or appliances will be replaced only after 3 years have elapsed since such dentures or appliances were provided under any plan program, unless the denture or appliance becomes unserviceable due to illness or other causes not controlled by other means. Replacement of dentures, appliances, or bridgework due to loss or theft are not covered. 7. Any dental treatment started prior to the Member's eligibility to receive services under this plan or started after a Member's termination are not covered. 8. Failure to follow the prescribed treatment or accidents occurring during the course of treatment may result in additional charges by your plan provider. 9. Failure to pay scheduled fees at the time service is rendered may prevent future dental services from being received until all fees have been paid in full. 10. Services provided by non-participating dentists are not covered. 11. Services which, in the opinion of the attending dentist, are not necessary for the patient's dental health, or are contrary to established dental ethics are not covered. 12. Cosmetic dental procedures are covered only if the attending dentist and patient agree on the specific procedure. 13. Services which are compensable under Worker's Compensation or employer liability laws are not covered. 14. General anesthesia and IV sedation are not covered. 15. Myofunctional therapy procedure for training, treating or developing muscles in and around the jaw or mouth including TMJ are not covered except by participating plan specialists. 16. Any dental procedure or service that cannot be performed in the dental office due to general and/or physical limitations of a member are not covered. 17. Expenses incurred for dental procedures initiated prior to member's eligibility or after termination are not covered. 18. Any services that the Participating General Dentist recommends be performed by a specialist are covered only by a plan participating specialist. 19. The liability of Beta Health Association, Inc. is limited to the return of the membership fees paid for one year by the member. 20. Extractions for asymptomatic third molars (wisdom teeth) are not covered unless causing movement of the teeth. An example of symptomatic include severe decay, and ontogenic cysts, chronic pericoronitis, and infection. 21. The Beta Health Association, Inc. dental programs do not constitute dental insurance and are considered discount, fee-forservice dental plans. 22. Fees are subject to change on an as needed basis. Please contact Beta Health Association, Inc. for current fees. Current Dental Terminology American Dental Association Page 4

12 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 Complete Participating Provider Directory ( Alpha and Choice Dental Plan including Orthodontists) Plan providers are listed in alphabetical order according to city. The most up to date provider listings can be found at You can also call or for assistance. All dentists listed are excepting new patients. Contact the office directly if you wish to verify. NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES General Dentists Dr. Richard Williams Dr. Richard Williams ADP # Edison Alamosa General Dentist *, **, C, E1-2, E3-4, N Dr. Frank Welch Welch Dental, LLC CDP # Crestone Ave Alamosa General Dentist *, E1-2 Dr. Christopher Welch Welch Dental, LLC CDP # Crestone Ave Alamosa General Dentist *, E1-2 Dr. Shayna Bahr Comfort Dental - North Arvada ADP # W. 80th Ave Arvada General Dentist *, **, C, E1-2, E3-4 Dr. Kathy Tomlinson Comfort Dental - North Arvada ADP # W. 80th Ave Arvada General Dentist *, **, C, E1-2, E3-4 Dr. Juan Materon Comfort Dental - North Arvada ADP # W. 80th Ave Arvada General Dentist *, **, C, E1-2, E3-4 Dr. Anita Vedi New Impressions Dental ADP # W. 88th Ave Arvada General Dentist t **, C, E1-2 Dr. Alan Bueltel Comfort Dental - Arvada ADP # W. 64th Ave Arvada General Dentist *, C, E1-2, E3-4 Dr. Mark Dean Comfort Dental - Arvada ADP # W. 64th Ave Arvada General Dentist *, C, E1-2, E3-4 Dr. Neil Zimmet Comfort Dental - Arvada ADP # W. 64th Ave Arvada General Dentist *, C, E1-2, E3-4 Dr. James R. Mayo Comfort Dental - Arvada ADP # W. 64th Ave Arvada General Dentist *, C, E1-2, E3-4 Dr. Roy Theriot Dr. Roy Theriot ADP # S. Havana, # Aurora General Dentist *, C Dr. Tiffany Fritz Bright Now Dental - Smoky Hill ADP # Prospect Ave., Ste. #hv2be Aurora General Dentist *, C, E1-2, E3-4 Dr. Chelsea Deutscher Bright Now Dental - Smoky Hill ADP # Prospect Ave., Ste. #hv2be Aurora General Dentist *, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Smoky Hill ADP # Prospect Ave., Ste. #hv2be Aurora General Dentist *, C, E1-2, E3-4 Dr. Mona Omran Bright Now Dental - Smoky Hill ADP # Prospect Ave., Ste. #hv2be Aurora General Dentist *, C, E1-2, E3-4 Dr. Bob Allen Comfort Dental - Iliff & Tower Rd. ADP # E. Iliff Ave., Suite Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Ekapoj Thongin Comfort Dental - Iliff & Tower Rd. ADP # E. Iliff Ave., Suite Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Clyde A. Bowden Clyde A. Bowden ADP # E. Alameda Ave Aurora General Dentist C, E1-2, N Dr. Kris Komanduri Hanu Dental Care ADP # E. Cornell Ave. # Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Gerald Edwards Comfort Dental - Aurora ADP # S. Peoria Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Matthew Rowan Comfort Dental - Aurora ADP # S. Peoria Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Zachary D. Bergeson Comfort Dental - Aurora ADP # S. Peoria Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Jeffrey Gilliam Comfort Dental - Aurora ADP # S. Peoria Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Michael Millward Comfort Dental - Orchard Rd. ADP # E. Orchard Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Jeffrey Hamilton Comfort Dental - Orchard Rd. ADP # E. Orchard Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Asha Chinni Comfort Dental - Orchard Rd. ADP # E. Orchard Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Mark Lawson Village Park Dental ADP # E. Mississippi Ave Aurora General Dentist *, C, E1-2, E3-4 Dr. Christopher Bentley Grandview Dental ADP # S. Liverpool St. #-A Aurora General Dentist **, C, E1-2, E3-4 Dr. Zachary D. Bergeson Comfort Dental-Havana ADP # E. Colfax Ave. # Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Jeffrey Gilliam Comfort Dental-Havana ADP # E. Colfax Ave. # Aurora General Dentist *, **, C,E1-2, E3-4 Dr. Jeffrey A. Varner Comfort Dental - East Aurora ADP # S. Chambers Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Jim Parfitt Comfort Dental - East Aurora ADP # S. Chambers Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Page 1 of 10

13 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Richard Doerhoff Comfort Dental - East Aurora ADP # S. Chambers Rd Aurora General Dentist *, **, C, E1-2, E3-4, N Dr. Barry Wohlgemuth Wohlgemuth & Rush, DDS ADP # S. Havana, # Aurora General Dentist C, N Dr. Steven Rush Wohlgemuth & Rush, DDS ADP # S. Havana, # Aurora General Dentist C, N Dr. Thomas E. Daniel Dr. Thomas E. Daniel ADP # Havana Aurora General Dentist C Dr. Marc W. Reissner Blue Mesa Dental - S. Chambers Rd. ADP # S. Chambers Rd Aurora General Dentist **, C, E1-2, E3-4 Dr. Dwayne A. Moore Blue Mesa Dental - S. Chambers Rd. ADP # S. Chambers Rd Aurora General Dentist **, C, E1-2, E3-4 Dr. Richard Handelman Blue Mesa Dental - S. Chambers Rd. ADP # S. Chambers Rd Aurora General Dentist **, C, E1-2, E3-4 Dr. Craig A. Mellor Bright Now Dental - S. Tower Rd. ADP # S. Tower Rd., #c Aurora General Dentist *, **, C, E1-2 Dr. Thomas Mulheran Bright Now Dental - S. Tower Rd. ADP # S. Tower Rd., #c Aurora General Dentist *, **, C, E1-2 Dr. Traver L. Maxwell Comfort Dental - Quincy Buckley ADP # E. Quincy D1-D Aurora General Dentist **, C, E1-2 Dr. Nicole Ward Comfort Dental - Quincy Buckley ADP # E. Quincy D1-D Aurora General Dentist **, C, E1-2 Dr. Camillo Dilizia Comfort Dental - Quincy Buckley ADP # E. Quincy D1-D Aurora General Dentist **, C, E1-2 Dr. James Liu Comfort Dental - Quincy Buckley ADP # E. Quincy D1-D Aurora General Dentist **, C, E1-2 Dr. John W. Thousand, Iii Comfort Dental - Quincy Buckley ADP # E. Quincy D1-D Aurora General Dentist **, C, E1-2 Dr. Nelson S. Joo Nelson S. Joo, DMD CDP # S. Fraser St. # Aurora General Dentist *, C, E1-2, E3-4 Dr. Sharon Fahmy Sharon Fahmy, DDS CDP # E. Rice Place # Aurora General Dentist C Dr. Farhad Farbod Farhad Farbod, DMD, PC CDP # E. Hampden Ave., # Aurora General Dentist *, C, E1-2, E3-4 Dr. Falona Glenn Falona Glenn, DDS, PC CDP # S. Chambers Rd Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Gerald Glenn Falona Glenn, DDS, PC CDP # S. Chambers Rd Aurora General Dentist *, **, C, E1-2, E3-4 Dr. Davood Manshadi Kids Choice Dental CDP # E. Colfax Ave., B Aurora General Dentist *, C, E1-2, E3-4 Dr. Mario Montanez Kids Choice Dental CDP # E. Colfax Ave., B Aurora General Dentist *, C, E1-2, E3-4 Dr. Lisa Sheldon Comfort Dental - Boulder ADP # Arapahoe Rd Boulder General Dentist *, C, E1-2, E3-4 Dr. Mark Cannon Comfort Dental - Boulder ADP # Arapahoe Rd Boulder General Dentist *, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Boulder ADP # Folsom St Boulder General Dentist *, C, E1-2, E3-4 Dr. Chelsea Deutscher Bright Now Dental - Boulder ADP # Folsom St Boulder General Dentist *, C, E1-2, E3-4 Dr. Pasco Scarpella Platte River Family Dental, PC CDP # Platte River Blvd., Unit E Brighton General Dentist *, **, C, E1-2 Dr. Lyndon Mata Mata Dental ADP # W. 120th Ave., # Broomfield General Dentist *, C, E1-2, N Dr. Hani Marogil Hani Marogil DMD, PC CDP # E. 1st Ave., # Broomfield General Dentist C, E1-2 Dr. Vikash Kanchanlal Shadow Rock Dentistry ADP # Wilcox St. # Castle Rock General Dentist *, **, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Castle Rock ADP # S. Perry St., #105-A Castle Rock General Dentist None Dr. Malgorzata R. Korosciel Bright Now Dental - Castle Rock ADP # S. Perry St., #105-A Castle Rock General Dentist None Dr. Margarita Aleksanyan Guaranteed Smiles - Southglenn ADP # E. Easter Ave., # Centennial General Dentist C, E1-2, E3-4 Dr. Sarah J. Meyer Sarah J. Meyer DDS ADP # S. Vine St Centennial General Dentist *, C Dr. Adam Mcveigh Comfort Dental - Centennial ADP # S. Quebec St., Unit A Centennial General Dentist *, C, E1-2, E3-4 Dr. Derrick Q. Price Comfort Dental - Centennial ADP # S. Quebec St., Unit A Centennial General Dentist *, C, E1-2, E3-4 Dr. Murray Jacobs Comfort Dental - Centennial ADP # S. Quebec St., Unit A Centennial i l General l Dentist t *, * C, E1-2, E3-4 Dr. Jeanette Berner Comfort Dental - Centennial ADP # S. Quebec St., Unit A Centennial General Dentist *, C, E1-2, E3-4 Dr. Kevin Marshall Comfort Dental - Centennial ADP # S. Quebec St., Unit A Centennial General Dentist *, C, E1-2, E3-4 Dr. William Case Dr. William Case ADP # E. Orchard Rd., # Centennial General Dentist *, C Dr. Neal Wilsted Neal K. Wilsted, DDS CDP # S. University Blvd. # Centennial General Dentist *, C Dr. Luis J. Bravo Luis J. Bravo, DMD CDP # S. Vine St., # Centennial General Dentist *, **, C, E1-2 Dr. Richard H. Wiedey Dr. Richard H. Wiedey ADP # North Circle # Colorado Springs General Dentist **, E1-2, E3-4, N Dr. Michael Stoor Comfort Dental - Citadel Crossing ADP # N. Academy Blvd Colorado Springs General Dentist *, C, E1-2 Dr. Travis Probst Comfort Dental - Citadel Crossing ADP # N. Academy Blvd Colorado Springs General Dentist *, C, E1-2 Page 2 of 10

14 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Scott Probst Comfort Dental - Citadel Crossing ADP # N. Academy Blvd Colorado Springs General Dentist *, C, E1-2 Dr. Christian Lovejoy Comfort Dental - North Powers ADP # Stetson Hills Blvd Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Dustin B. Dial Comfort Dental - North Powers ADP # Stetson Hills Blvd Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Jamison Miller Comfort Dental - North Powers ADP # Stetson Hills Blvd Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Dwight Douglas Olson Comfort Dental - North Powers ADP # Stetson Hills Blvd Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Patrick Hudson Comfort Dental - Austin Bluffs ADP # A North Academy Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Dan Kingsford Comfort Dental - Austin Bluffs ADP # A North Academy Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Jeremy Bullock Comfort Dental - Austin Bluffs ADP # A North Academy Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Parkmoor Village ADP # N. Academy Blvd., # Colorado Springs General Dentist C, E1-2, E3-4 Dr. Paul Hennegan Bright Now Dental - Parkmoor Village ADP # N. Academy Blvd., # Colorado Springs General Dentist C, E1-2, E3-4 Dr. Paul Rygg Jade/erindale Dental ADP # Erin Park Dr Colorado Springs General Dentist C, E1-2, E3-4 Dr. Kathleen Brower Jade/erindale Dental ADP # Erin Park Dr Colorado Springs General Dentist C, E1-2, E3-4 Dr. Joseph A. Woods Blue Mesa Citadel Dental, PC ADP # Citadel Dr. East # Colorado Springs General Dentist C, E1-2 Dr. Oliver M. Spaeth Broadmoor Valley Dental Care ADP # Broadmoor Valley Rd Colorado Springs General Dentist C, E1-2 Dr. Jay Johnson Comfort Dental-South Powers ADP # Space Center Dr. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Benjamin Weir Comfort Dental-South Powers ADP # Space Center Dr. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Kathleen Brower Rigby Dental PC ADP # N. Academy Blvd. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Ted L. Rigby Rigby Dental PC ADP # N. Academy Blvd. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Leopoldo Rodríguez Rigby Dental PC ADP # N. Academy Blvd. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Paul Rygg Rigby Dental PC ADP # N. Academy Blvd. # Colorado Springs General Dentist *, **, C, E1-2, E3-4 Dr. Angelo M. Camerino North Summit Dental Care ADP # Jet Stream Dr. # Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. Carolyn T. Camerino Centennial Dental Care PC. ADP # Silverstone Terr. # Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. David R. Baer Stafford Dental Group ADP # E. Pikes Peak Ave., # Colorado Springs General Dentist **, E1-2, E3-4 Dr. Jay D. Tippets Stafford Dental Group ADP # E. Pikes Peak Ave., # Colorado Springs General Dentist **, E1-2, E3-4 Dr. Christopher Bentley Bright Now Dental - Citadel Dr. ADP # Citadel Dr. East Colorado Springs General Dentist **, C, E1-2, E3-4, N Dr. Thomas Mulheran Bright Now Dental - Citadel Dr. ADP # Citadel Dr. East Colorado Springs General Dentist **, C, E1-2, E3-4, N Dr. Julia Arnold Interquest Dental Group, Inc. ADP # United Heights Dr. # Colorado Springs General Dentist C Dr. Paul Rodríguez Dr. Paul Rodríguez ADP # N. Tejon St., #d Colorado Springs General Dentist **, C, E1-2, E3-4 Dr. Paul Rygg Jade Dental Associates ADP # N. Tejon St., #a Colorado Springs General Dentist C, E1-2, E3-4 Dr. Colleen Jenson Jade Dental Associates ADP # N. Tejon St., #a Colorado Springs General Dentist C, E1-2, E3-4 Dr. Natalie Jones Comfort Dental - North Academy ADP # York Rd Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. Steve Carter Comfort Dental - North Academy ADP # York Rd Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. Christopher Hasselback Comfort Dental - North Academy ADP # York Rd Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. Peter Lovejoy Comfort Dental - North Academy ADP # York Rd Colorado Springs General Dentist *, C, E1-2, E3-4 Dr. Michael Gilbert Aspen Dental Associates CDP # E. Pikes Peak Ave., # Colorado Springs General Dentist *, **, E1-2 Dr. Gregory D. Mock Aspen Dental Associates CDP # E. Pikes Peak Ave., # Colorado Springs General Dentist t *, **, E1-2 Dr. Arnold Cullum Lowell District Dental, PC CDP # E. Fountain # Colorado Springs General Dentist *, E1-2, E3-4 Dr. Gregory Moore Gregory B. Moore, DDS CDP # E. Pikes Peak Ave., # Colorado Springs General Dentist C, E1-2 Dr. Stephen G. Sosdian Uptown Dental Associates CDP # N. Nevada Ave Colorado Springs General Dentist C, E1-2 Dr. Quynh Dung Vo Sosdian Uptown Dental Associates CDP # N. Nevada Ave Colorado Springs General Dentist C, E1-2 Dr. Glenn Thompson Glenn D. Thompson, DMD CDP # N. Murray Blvd Colorado Springs General Dentist E1-2 Dr. Jackson Anderson Jackson L. Anderson, DDS CDP # Omaha Blvd Colorado Springs General Dentist *, * C, E1-2 Dr. Nicolas Porter Comfort Dental -Commerce City ADP # Monaco St Commerce City General Dentist *, **, C, E1-2, E3-4 Dr. Ramsey Warner Comfort Dental -Commerce City ADP # Monaco St Commerce City General Dentist *, **, C, E1-2, E3-4 Page 3 of 10

15 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Owen Eames Comfort Dental -Commerce City ADP # Monaco St Commerce City General Dentist *, **, C, E1-2, E3-4 Dr. Jason Mahoney Comfort Dental-Conifer ADP # Conifer Rd Conifer General Dentist *, **, C, E1-2, E3-4 Dr. Jacqueline Blasko Comfort Dental-Conifer ADP # Conifer Rd Conifer General Dentist *, **, C, E1-2, E3-4 Dr. Teniel Seifert Comfort Dental-Conifer ADP # Conifer Rd Conifer General Dentist *, **, C, E1-2, E3-4 Dr. Robert Unrath Comfort Dental - North Denver ADP # W. 38th Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Gary Saddler Comfort Dental - North Denver ADP # W. 38th Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. John Adams Comfort Dental - North Denver ADP # W. 38th Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Lyda Martinez Comfort Dental - North Denver ADP # W. 38th Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Alan Coombs Alpha Dental Ii, PC ADP # S. Albion, # Denver General Dentist ** Dr. Jason Ray Hampden Family Dental ADP # E. Hampden Ave. #-A Denver General Dentist *, **, C, E1-2, E3-4 Dr. Thomas Sniegowski Dr. Thomas Sniegowski ADP # Dakin St., Ste. # Denver General Dentist *, E3-4, N Dr. Todd Light Comfort Dental - Cherry Creek ADP # University Blvd., # Denver General Dentist *, C, E1-2, E3-4 Dr. David Dinsmore Comfort Dental - Cherry Creek ADP # University Blvd., # Denver General Dentist *, C, E1-2, E3-4 Dr. Mark Jolsted Comfort Dental - Cherry Creek ADP # University Blvd., # Denver General Dentist *, C, E1-2, E3-4 Dr. Saul Escala Escala Family Dentistry ADP # S. Federal Blvd Denver General Dentist *, **, C, E1-2, E3-4 Dr. Sergio M. Lopez Sergio M. Lopez D.D.S. ADP # Cherry Creek N. Dr. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Douglas R. Koch Greentree Dental ADP # E. Hampden Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Richard H. Koch Greentree Dental ADP # E. Hampden Ave. # Denver General Dentist *, **, C, E1-2, E3-4 Dr. Chad Welch Southeast Denver Dental Associates ADP # S. Monaco Pkwy Denver General Dentist *, **, C, E1-2, E3-4 Dr. Janice Jones Southeast Denver Dental Associates ADP # S. Monaco Pkwy Denver General Dentist *, **, C, E1-2, E3-4 Dr. Donald Mardis Comfort Dental - East Colfax ADP # E. Colfax Ave Denver General Dentist *, **, C, E1-2 Dr. Gary Rotolo Comfort Dental - East Colfax ADP # E. Colfax Ave Denver General Dentist *, **, C, E1-2 Dr. Thomas Pyne Dr. Thomas Pyne ADP # E. 45th Ave., # Denver General Dentist *, C, E1-2, E3-4 Dr. Lindsey I Graf Bright Now Dental - Denver Downtown ADP # Arapahoe St., Ste. A Denver General Dentist C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Denver Downtown ADP # Arapahoe St., Ste. A Denver General Dentist C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Cherry Creek ADP # Cherry Creek Dr. North, # Denver General Dentist C, N Dr. David Koo Bright Now Dental - Cherry Creek ADP # Cherry Creek Dr. North, # Denver General Dentist C, N Dr. Lindsey I Graf Bright Now Dental - Cherry Creek ADP # Cherry Creek Dr. North, # Denver General Dentist C, N Dr. Christopher Bentley Bright Now Dental - Cherry Creek ADP # Cherry Creek Dr. North, # Denver General Dentist C, N Dr. David R. Huskey David R. Huskey, DDS ADP # S. Downing, #104 A Denver General Dentist C, E1-2, N Dr. Timothy Wachuta Dr. Timothy Wachuta ADP # S. Colorado Blvd Denver General Dentist C, E1-2, E3-4 Dr. Ekatrina Butkevich Dr. Timothy Wachuta ADP # S. Colorado Blvd Denver General Dentist C, E1-2, E3-4 Dr. Kenneth Chernoff Dr. Timothy Wachuta ADP # S. Colorado Blvd Denver General Dentist C, E1-2, E3-4 Dr. Kelly White Auraria Dental Centre ADP # W. Colfax, Ste. G Denver General Dentist **, E1-2, E3-4 Dr. Arnold Cullum Blake Street Dental, PC CDP # Blake St Denver General Dentist *, E1-2, E3-4 Dr. Shih Chien Shih M. Chien, DDS CDP # E. 84th Ave., #e Denver General Dentist t C, E1-2 Dr. Preet Clair Quebec Square Family Dentistry CDP # E. 35th Ave., # Denver General Dentist *, C, E1-2 Dr. Jason Ray Dentistry At Lincoln Center ADP # Washington Lane # Englewood General Dentist **, C, E1-2, E3-4 Dr. Neil Cowen Dr. Neil Cowen ADP # S. Lafayette, Suite Englewood General Dentist *, C, E1-2 Dr. David Rebber Comfort Dental - Englewood ADP # S. Broadway Englewood General Dentist *, C, E1-2, E3-4, N Dr. Larry Nessel Comfort Dental - Englewood ADP # S. Broadway Englewood General Dentist *, C, E1-2, E3-4, N Dr. James M. Brown Comfort Dental - Englewood ADP # S. Broadway a Englewood General Dentist *, C, E1-2, E3-4, N Dr. Brigitte Steeghs Brigitte Steeghs, DDS CDP # E. Prentice Ave., Suite A Englewood General Dentist *, C, E1-2 Dr. Hiba Kellow Comfort Dental-Westminster ADP # N. Federal Blvd Federal Heights General Dentist *, **, C, E1-2, E3-4 Page 4 of 10

16 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Cory S. Higginbotham Comfort Dental-Westminster ADP # N. Federal Blvd Federal Heights General Dentist *, **, C, E1-2, E3-4 Dr. Helen Stella Comfort Dental-Westminster ADP # N. Federal Blvd Federal Heights General Dentist *, **, C, E1-2, E3-4 Dr. David Yeats Comfort Dental-Westminster ADP # N. Federal Blvd Federal Heights General Dentist *, **, C, E1-2, E3-4 Dr. Ciaran Finbar Murphy Harbor Dental Clinic ADP # S. Timberline Rd.# Fort Collins General Dentist C, E1-2, E3-4 Dr. Jamie Fillmore Comfort Dental - Ft. Collins ADP # S. Lemay Fort Collins General Dentist C, E1-2, N Dr. Alois Tripam Comfort Dental - Ft. Collins ADP # S. Lemay Fort Collins General Dentist C, E1-2, N Dr. Douglas Haschke Comfort Dental - Ft. Collins ADP # S. Lemay Fort Collins General Dentist C, E1-2, N Dr. Katerina Sorensen Comfort Dental - Ft. Collins ADP # S. Lemay Fort Collins General Dentist C, E1-2, N Dr. Thomas Mulheran Bright Now Dental - Fort Collins ADP # E. Elizabeth St., # Fort Collins General Dentist C, E1-2 Dr. Scott Bares Bright Now Dental - Fort Collins ADP # E. Elizabeth St., # Fort Collins General Dentist C, E1-2 Dr. James Fischer Fischer Dental CDP # E. Prospect Rd., #b Fort Collins General Dentist *, C, E1-2, E3-4 Dr. Rich Wuerker Boardwalk Dental CDP # E. Boardwalk Dr. #g Fort Collins General Dentist *, C, E1-2, E3-4 Dr. Leon Green Boardwalk Dental CDP # E. Boardwalk Dr. #g Fort Collins General Dentist *, C, E1-2, E3-4 Dr. Zachery Green Boardwalk Dental CDP # E. Boardwalk Dr. #g Fort Collins General Dentist *, C, E1-2, E3-4 Dr. George V. Ranta Mesa Ridge Dental Center CDP # Mesa Ridge Pkwy Fountain General Dentist *, **, C, E1-2, E3-4 Dr. Candace Pfister Mesa Ridge Dental Center CDP # Mesa Ridge Pkwy Fountain General Dentist *, **, C, E1-2, E3-4 Dr. Kajsa Novembre Mesa Ridge Dental Center CDP # Mesa Ridge Pkwy Fountain General Dentist *, **, C, E1-2, E3-4 Dr. Ryan Reposa Mesa Ridge Dental Center CDP # Mesa Ridge Pkwy Fountain General Dentist *, **, C, E1-2, E3-4 Dr. Thomas L. Losacco Dr. Thomas L. Losacco ADP # th St Georgetown General Dentist *, C, E1-2, E3-4, N Dr. Benjamin D. Coon Glenwood Meadows Dental ADP # A Market Street Glenwood Springs General Dentist **, C, E1-2, E3-4 Dr. Brian Talley Comfort Dental - Glenwood Springs ADP # Grand Ave Glenwood Springs General Dentist *, **, C, E1-2, E3-4 Dr. Michael Shea Comfort Dental - Glenwood Springs ADP # Grand Ave Glenwood Springs General Dentist *, **, C, E1-2, E3-4 Dr. Ekatrina Butkevich Dr. Timothy Wachuta ADP # Jackson St Golden General Dentist C, E1-2, E3-4 Dr. Timothy Wachuta Dr. Timothy Wachuta ADP # Jackson St Golden General Dentist C, E1-2, E3-4 Dr. Kenneth Chernoff Dr. Timothy Wachuta ADP # Jackson St Golden General Dentist C, E1-2, E3-4 Dr. Scott Welch Golden View Dental ADP # Simms St., #e Golden General Dentist *, **, C, E1-2, E3-4 Dr. Heath Colledge Comfort Dental - Golden ADP # S. Golden Rd Golden General Dentist *, **, C, E1-2, E3-4 Dr. Paulette Dilizia Comfort Dental - Golden ADP # S. Golden Rd Golden General Dentist *, **, C, E1-2, E3-4 Dr. Nicholas L. Groneman Comfort Dental - Golden ADP # S. Golden Rd Golden General Dentist *, **, C, E1-2, E3-4 Dr. Jason Noah Comfort Dental - Golden ADP # S. Golden Rd Golden General Dentist *, **, C, E1-2, E3-4 Dr. John Burchfield J.R. Burchfield, DDS CDP # Jackson St Golden General Dentist C, E1-2 Dr. James M. Tarr Dr. James M. Tarr ADP # W. Pinyon Ave Grand Junction General Dentist C, E1-2 Dr. Robert R. Harmen Robert Harmen ADP # N. 1st St., Unit D Grand Junction General Dentist *, C Dr. Matthew Hudson Hudson Family Dental ADP # Walnut Ave. # Grand Junction General Dentist *, C, E1-2, E3-4 Dr. Thomas Sorensen Comfort Dental-Grand Junction ADP # North Ave Grand Junction General Dentist *, **, C, E1-2, E3-4 Dr. James Bradley Comfort Dental-Grand Junction ADP # North Ave Grand Junction General Dentist t *, **, C, E1-2, E3-4 Dr. Michael Shea Comfort Dental-Grand Junction ADP # North Ave Grand Junction General Dentist *, **, C, E1-2, E3-4 Dr. Stephen Brown Dr. Stephen Brown ADP # W. 16th St., Bldg. 3, Ste. S Greeley General Dentist **, E1-2 Dr. Patrick Rinaldis Comfort Dental - Greeley ADP # West 10th St Greeley General Dentist **, C, E1-2, E3-4 Dr. Courtney Stevens Comfort Dental - Greeley ADP # West 10th St Greeley General Dentist **, C, E1-2, E3-4 Dr. Andrey A. Kondratenko Comfort Dental - Greeley ADP # West 10th St Greeley General Dentist **, C, E1-2, E3-4 Dr. Alex Knecht Sunrise Dental Center ADP # A. St Greeley General Dentist *, **, C, E1-2, E3-4 Dr. Dinorah Moya Sunrise Dental Center ADP # A. St Greeley General Dentist *, **, C, E1-2, E3-4 Dr. Kent Day Sunrise Dental Center ADP # A. St Greeley General Dentist *, **, C, E1-2, E3-4 Page 5 of 10

17 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Patrick Harrison Sunrise Dental Center ADP # A. St Greeley General Dentist *, **, C, E1-2, E3-4 Dr. Shivaun Mcartor Sunrise Dental Center ADP # A. St Greeley General Dentist *, **, C, E1-2, E3-4 Dr. Nicholas Jimison Nicholas A. Jamison, Ii DDS CDP # W. 20th Street Rd., Ste. A Greeley General Dentist *, C Dr. Michael Love Comfort Dental - Highlands Ranch ADP # W. County Line Rd Highlands Ranch General Dentist *, **, C, E1-2, E3-4 Dr. Khiem Hoang Comfort Dental - Highlands Ranch ADP # W. County Line Rd Highlands Ranch General Dentist *, **, C, E1-2, E3-4 Dr. Michael Vetowich Comfort Dental - Highlands Ranch ADP # W. County Line Rd Highlands Ranch General Dentist *, **, C, E1-2, E3-4 Dr. Mark Jolsted Comfort Dental - Highlands Ranch ADP # W. County Line Rd Highlands Ranch General Dentist *, **, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Highlands Ranch ADP # Highlands Rnch. Pkwy # Highlands Ranch General Dentist *, **, E1-2, E3-4, N Dr. Henry D. Ahn Bright Now Dental - Highlands Ranch ADP # Highlands Rnch. Pkwy # Highlands Ranch General Dentist *, **, E1-2, E3-4, N Dr. Hanaa Jebril Comfort Dental - Lafayette ADP # W. South Boulder Rd., # Lafayette General Dentist *, **, C, E1-2, E3-4 Dr. Randal Silver Comfort Dental - Lafayette ADP # W. South Boulder Rd., # Lafayette General Dentist *, **, C, E1-2, E3-4 Dr. Eric Rosengren Comfort Dental - Lafayette ADP # W. South Boulder Rd., # Lafayette General Dentist *, **, C, E1-2, E3-4 Dr. Pamela Lerfald Comfort Dental - Lafayette ADP # W. South Boulder Rd., # Lafayette General Dentist *, **, C, E1-2, E3-4 Dr. Efren Martinez Dr. Efren Martinez ADP # S. Wadsworth Lakewood General Dentist **, E1-2, E3-4 Dr. Bruce H. Johnson Bruce H. Johnson ADP # W. Girton Dr Lakewood General Dentist *, **, C, E1-2 Dr. Richard Glucksman Alpha Dental Xx ADP # W. Jefferson, # Lakewood General Dentist *, N Dr. Jennifer K. Lee Bright Now Dental - Lakewood ADP # W. Colfax Ave., #d Lakewood General Dentist *, C, E1-2 Dr. Thomas Mulheran Bright Now Dental - Lakewood ADP # W. Colfax Ave., #d Lakewood General Dentist *, C, E1-2 Dr. Timothy Schroeder Timothy Schroeder, DDS CDP # W. Jewell # Lakewood General Dentist *, C, E1-2 Dr. Owen Crockett Owen C. Crockett, DDS CDP # Wadsworth Lakewood General Dentist None Dr. James T. Kern James T. Kern, DDS CDP # W. Jewell Ave., #l Lakewood General Dentist C Dr. Richard Nichols Cosmetic Complete Dentistry CDP # W. Hampden Ave., # Lakewood General Dentist *, **, C, E1-2 Dr. Ibraheem Ackall Highplains Community Health Center ADP # Kendall Drive Lamar General Dentist **, C, E1-2 Dr. Bill Bender Dr. Bill Bender ADP # nd St Lasalle General Dentist *, **, C, E1-2 Dr. Richard J. Birkel Comfort Dental- Littleton Blvd. ADP # B W. Littleton Blvd Littleton General Dentist *, **, C, E1-2, E3-4, N Dr. Jeffrey Spiegel Comfort Dental- Littleton Blvd. ADP # B W. Littleton Blvd Littleton General Dentist *, **, C, E1-2, E3-4, N Dr. David Kim Comfort Dental - Littleton ADP # W. Coal Mine Ave Littleton General Dentist *, C, E1-2, E3-4 Dr. Thomas Klumb Comfort Dental - Littleton ADP # W. Coal Mine Ave Littleton General Dentist *, C, E1-2, E3-4 Dr. Bill Oldershaw Comfort Dental - Littleton ADP # W. Coal Mine Ave Littleton General Dentist *, C, E1-2, E3-4 Dr. Brad Weekes Comfort Dental - Littleton ADP # W. Coal Mine Ave Littleton General Dentist *, C, E1-2, E3-4 Dr. Ellias Najjar Belleview Dental Associates ADP # W. Belleview Littleton General Dentist * Dr. Margareta Pavel Dutch Creek Dental ADP # W. Coal Mine Ave., # Littleton General Dentist *, C, E1-2, E3-4 Dr. James Preston James M. Preston, DDS CDP # Platte Canyon Rd Littleton General Dentist *, C, E1-2 Dr. Jason Blanchard Blanchard & Richardson Family Dentistry CDP # S. Lincoln St. # Littleton General Dentist *, **, C, E1-2 Dr. Brian Richardson Blanchard & Richardson Family Dentistry CDP # S. Lincoln St. # Littleton General Dentist *, **, C, E1-2 Dr. Cindy Kempton Cindy Kempton, DDS CDP # S. Broadway, # Littleton t General l Dentist t *, **, C, E1-2 Dr. Tram Tran Tram Tran, DDS, LLC CDP # W. Belleview Ave Littleton General Dentist *, C, E1-2 Dr. M. William Meyer Littleton Dental Associates CDP # W. Ken Caryl Ave Littleton General Dentist *, C, E1-2 Dr. Ramzi Matar Littleton Dental Associates CDP # W. Ken Caryl Ave Littleton General Dentist *, C, E1-2 Dr. David Gryzick Littleton Dental Associates CDP # W. Ken Caryl Ave Littleton General Dentist *, C, E1-2 Dr. Donald Hobbs Littleton Dental Associates CDP # W. Ken Caryl Ave Littleton General Dentist *, C, E1-2 Dr. Richard Handelman Dentistry At The Crest ADP # Park Meadows Dr. #-B Lone Tree General Dentist *, **, C, E1-2, E3-4 Dr. Daniel Larscheid Dentistry At The Crest ADP # Park Meadows Dr. #-B Lone Tree General Dentist *, **, C, E1-2, E3-4 Dr. M. Shawn Lawler Four Seasons Dental CDP # Rosemont Ave., # Lone Tree General Dentist C, E1-2 Page 6 of 10

18 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Jolly Johnson Comfort Dental - Longmont ADP # Mountain View Longmont General Dentist *, **, C, E1-2, E3-4 Dr. Stephen Sidwell Comfort Dental - Longmont ADP # Mountain View Longmont General Dentist *, **, C, E1-2, E3-4 Dr. Conrad Stutznegger Comfort Dental - Longmont ADP # Mountain View Longmont General Dentist *, **, C, E1-2, E3-4 Dr. Aaron D. Mortensen Comfort Dental - Longmont ADP # Mountain View Longmont General Dentist *, **, C, E1-2, E3-4 Dr. Stephen Brown Affordable Dental Clinic ADP # Terry St Longmont General Dentist *, E1-2 Dr. David R. Maki Bright Now Dental - Longmont ADP #59 15 Ken Pratt Blvd., # Longmont General Dentist *, C, E1-2, E3-4 Dr. Lauren Peterson Bright Now Dental - Longmont ADP #59 15 Ken Pratt Blvd., # Longmont General Dentist *, C, E1-2, E3-4 Dr. Thomas Mulheran Bright Now Dental - Longmont ADP #59 15 Ken Pratt Blvd., # Longmont General Dentist *, C, E1-2, E3-4 Dr. Mona Omran Bright Now Dental - Longmont ADP #59 15 Ken Pratt Blvd., # Longmont General Dentist *, C, E1-2, E3-4 Dr. Abraham Miller Comfort Dental - Louisville ADP # Mccaslin Blvd., #b Louisville General Dentist *, **, C, E1-2, E3-4 Dr. Stephen Spencer Comfort Dental - Louisville ADP # Mccaslin Blvd., #b Louisville General Dentist *, **, C, E1-2, E3-4 Dr. Doug Duey Comfort Dental - Louisville ADP # Mccaslin Blvd., #b Louisville General Dentist *, **, C, E1-2, E3-4 Dr. Susan Kutis Bright Now Dental - Loveland ADP # W. 29th St., # Loveland General Dentist **, E1-2 Dr. James A. Fisher Bright Now Dental - Loveland ADP # W. 29th St., # Loveland General Dentist **, E1-2 Dr. Thomas Mulheran Bright Now Dental - Loveland ADP # W. 29th St., # Loveland General Dentist **, E1-2 Dr. Jeffery Bourne Comfort Dental- North Loveland ADP # W. 64th St Loveland General Dentist **, C, E1-2, E3-4, N Dr. Mikal Lindman Comfort Dental- North Loveland ADP # W. 64th St Loveland General Dentist **, C, E1-2, E3-4, N Dr. Patrick Harrison Loveland Community Health Center ADP # N. Cleveland Ave Loveland General Dentist *, **, C, E1-2, E3-4 Dr. Christopher Hasselback Comfort Dental-Monument ADP # W. Highway Monument General Dentist *, C, E1-2, E3-4 Dr. Michael Gioia Comfort Dental-Monument ADP # W. Highway Monument General Dentist *, C, E1-2, E3-4 Dr. Victoria L. Driskill Comfort Dental-Monument ADP # W. Highway Monument General Dentist *, C, E1-2, E3-4 Dr. Steve Carter Comfort Dental-Monument ADP # W. Highway Monument General Dentist *, C, E1-2, E3-4 Dr. Stewart Moss Stuart Moss & Associates ADP #4 421 W. 104th Ave., # Northglenn General Dentist *, **, C, E1-2 Dr. Ronald J. Freimuth Comfort Dental - Parker ADP # Stroh Ranch Court Parker General Dentist *, C, E1-2, E3-4, N Dr. Scott Henderson Comfort Dental - Parker ADP # Stroh Ranch Court Parker General Dentist *, C, E1-2, E3-4, N Dr. Trevor G. Johnson Comfort Dental - Parker ADP # Stroh Ranch Court Parker General Dentist *, C, E1-2, E3-4, N Dr. Kathleen Cortese Parker Dental Center ADP # S. Pikes Peak Dr. # Parker General Dentist **, C, E1-2, E3-4 Dr. Michael Miller Foxfield Dental ADP # E. Arapahoe Rd. # Parker General Dentist *, **, C, E1-2, E3-4 Dr. Michael G. Hale Dr. Michael G. Hale ADP # E. Mainstreet #r Parker General Dentist C, N Dr. Joel Stafford Comfort Dental-Falcon Hills ADP # Meridian Market View # Peyton General Dentist *, **, C, E1-2, E3-4 Dr. Jonathan Harvey Comfort Dental-Falcon Hills ADP # Meridian Market View # Peyton General Dentist *, **, C, E1-2, E3-4 Dr. Chad J. Murdock Comfort Dental-Falcon Hills ADP # Meridian Market View # Peyton General Dentist *, **, C, E1-2, E3-4 Dr. Vikash Kanchanlal Gentle Touch Family Dentistry ADP # Sandalwood Lane Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Anthony Knowlton Sandalwood Dental Care Center ADP # Sandalwood Lane Pueblo General Dentist *, C, E1-2, E3-4 Dr. Tony G. Oreskovich Oreskovich Dental ADP # Pueblo Blvd. Way, # Pueblo General Dentist E1-2, E3-4 Dr. Tony I. Oreskovich Oreskovich i Dentalt l ADP # Pueblo Blvd. Way, # Pueblo General Dentist t E1-2, E3-4 Dr. Richard C. Moreschini Dr. Richard C. Moreschini ADP # W. 6th St Pueblo General Dentist C, E1-2, N Dr. Karleen L. Trefil Comfort Dental - Pueblo - North ADP # W. Us Hwy. 50, Ste. A Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Phillip Holden Comfort Dental - Pueblo - North ADP # W. Us Hwy. 50, Ste. A Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Elden M. Rice Comfort Dental - Pueblo - North ADP # W. Us Hwy. 50, Ste. A Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Brady T. Smith Comfort Dental - Pueblo - North ADP # W. Us Hwy. 50, Ste. A Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Jeffery A. Moeller Comfort Dental - Pueblo - South ADP # S. Pueblo Blvd Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Bradley Michael Almond Comfort Dental - Pueblo - South ADP # S. Pueblo Blvd Pueblo General Dentist *, **, C, E1-2, E3-4 Dr. Ralph Downey Comfort Dental - Pueblo - South ADP # S. Pueblo Blvd Pueblo General Dentist *, **, C, E1-2, E3-4 Page 7 of 10

19 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. Gino Ortegon Dr. Gino Ortegon ADP # W.12th St Pueblo General Dentist **, C, E1-2, N Dr. Gary Graves Dr. Gary Graves ADP # S. Pueblo Blvd Pueblo General Dentist *, **, C, E1-2 Dr. David Robinson David B. Robinson, DDS, PC CDP # Bonforte Blvd Pueblo General Dentist *, C, E1-2 Dr. Tony Roberts Dr. Tony Roberts CDP # N. Grand Ave Pueblo General Dentist *, C, E1-2, E3-4 Dr. Duilio Stricca Duilio A. Stricca,, DDS CDP # W. Abriendo Ave Pueblo General Dentist C, E1-2 Dr. Thomas W. Ready Gentle Dental CDP # S. Pueblo Blvd Pueblo General Dentist * Dr. Greg Philson Dr. Greg A. Philson, PC CDP # W. Abriendo Pueblo General Dentist E1-2 Dr. Mark Hurd Mark D. Hurd, DDS CDP # Outlook Blvd., Ste. C Pueblo General Dentist *, C, E1-2 Dr. Lorraine Mundy Comfort Dental- Summit County ADP # Blue River Pkwy #a Silverthorne General Dentist *, C, E1-2, E3-4 Dr. John Rollow, Iv Comfort Dental- Summit County ADP # Blue River Pkwy #a Silverthorne General Dentist *, C, E1-2, E3-4 Dr. Tim Townsend Tim F. Townsend, DDS CDP # Anglers Dr. # Steamboat Springs General Dentist C, E1-2 Dr. Randall C. Jones Randall C. Jones ADP # S. 3rd Ave Sterling General Dentist *, C, E1-2, E3-4 Dr. Matthew Janda Matthew C. Janda, DDS CDP # Iris Dr Sterling General Dentist *, **, C, E1-2, E3-4 Dr. Hanh H. Phi Kids And Family Dentistry And Orthodontics CDP # E. 120th Ave. # Thornton General Dentist *, **, C, E1-2, E3-4 Dr. Phillip K. Johnson Kids And Family Dentistry And Orthodontics CDP # E. 120th Ave. # Thornton General Dentist *, **, C, E1-2, E3-4 Dr. Christopher Welch Welch Dental CDP # E. Main St Trinidad General Dentist *, E1-2 Dr. Frank Welch Welch Dental CDP # E. Main St Trinidad General Dentist *, E1-2 Dr. Phil Warlick Phil Warlick, DDS, Inc. CDP # S. Albert Ave Walsenberg General Dentist *, C, E1-2 Dr. Malgorzata R. Korosciel Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Thomas Mulheran Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Lindsey Schroepfer Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Luan K. Tran Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Travis Willey Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Chelsea Deutscher Bright Now Dental - Westminster ADP # W. 104th Avenue Westminster General Dentist C, E1-2 Dr. Alan Bueltel Kenneth J. Polke, DDS, PC CDP # Melody Dr Westminster General Dentist *, C, E1-2, E3-4 Dr. Kenneth Polke Kenneth J. Polke, DDS, PC CDP # Melody Dr Westminster General Dentist *, C, E1-2, E3-4 Dr. Claude Pareja Westminster Dental Associates CDP # W. 72nd Ave Westminster General Dentist *, **, C, E1-2, E3-4 Dr. William Mcglashan Comfort Dental - Wheat Ridge ADP # W. 26th Ave # Wheat Ridge General Dentist *, **, C, E1-2, E3-4 Dr. Sara Marchbanks Comfort Dental - Wheat Ridge ADP # W. 26th Ave # Wheat Ridge General Dentist *, **, C, E1-2, E3-4 Dr. Lewis Sherman Comfort Dental - Wheat Ridge ADP # W. 26th Ave # Wheat Ridge General Dentist *, **, C, E1-2, E3-4 Dr. Christopher Hasselback Comfort Dental - Wheat Ridge ADP # W. 26th Ave # Wheat Ridge General Dentist *, **, C, E1-2, E3-4 Dr. David R. Maki Aspen Hill Dental, PC ADP # W. 38th Ave Wheat Ridge General Dentist *, **, C, E1-2, E3-4 Dr. Alan Bernbaum Alan N. Bernbaum, DDS CDP # W. 38th Ave Wheat Ridge General Dentist *, C, E1-2 Dr. Bryan Dahler Bryan M. Dahler, DDS, PC CDP # Kipling St Wheat Ridge General Dentist *, C, E1-2, E3-4 Dr. Anthony Musella Wheatridge Oral Surgery Not Needed 7760 W. #38th. Ave., Ste Wheat Ridge General Dentist None Dr. Gregory E. Micheli Dental Associates At Eagles Nest ADP # Morning Sun Dr Woodland d Park General l Dentist t *, C, E1-2, E3-4 Dr. Eric T. Helland Dental Associates At Eagles Nest ADP # Morning Sun Dr Woodland Park General Dentist *, C, E1-2, E3-4 Orthodontists Dr. James H. Mason Colo Orthodontics Not Needed 6390 Gardenia St., # Arvada Orthodontist N/A Dr. Galen L. Callender Galen L. Callender Not Needed 7207 Grandview Ave Arvada Orthodontist N/A Dr. John Bailey Colo Orthodontics Not Needed 2993 S. Peoria St., # Aurora Orthodontist N/A Dr. James H. Mason Colo Orthodontics Not Needed 2993 S. Peoria St., # Aurora Orthodontist N/A Dr. Jack E. Duran Dr. Jack E. Duran Not Needed E. Mississippi Ave., # Aurora Orthodontist N/A Dr. Roy M. Lorenz Roy M. Lorenz, DMD, MS Not Needed E. Hampden Ave. # Aurora Orthodontist N/A Page 8 of 10

20 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES Dr. John Walker Dr. John Walker Not Needed 350 Broadway # Boulder Orthodontist N/A Dr. David E. Gold David E. Gold Jr. Not Needed 9025 E. Mineral Cir. # Centennial Orthodontist N/A Dr. David Schroeder Apple Orthodontics Not Needed 1694 E. Cheyenne Mtn. Blvd Colorado Springs Orthodontist N/A Dr. Louis Talmoumis Apple Orthodontics Not Needed 1694 E. Cheyenne Mtn. Blvd Colorado Springs Orthodontist N/A Dr. Scott Suter Front Range Ortho Not Needed 3100 N. Academy Blvd., # Colorado Springs Orthodontist N/A Dr. Voytek Bobak Dr. Voytek Bobak Not Needed Pleasant Park Rd., #b Conifer Orthodontist N/A Dr. Andrey Nazarov Allegro Orthodontics Not Needed 9450 E. Mississippi Ave. #a Denver Orthodontist N/A Dr. Damon C. Wilkerson Clear Choice Orthodontics Not Needed 2617 E. 3rd Ave Denver Orthodontist N/A Dr. Michael D. Bellon Dr. Michael D. Bellon Not Needed 7200 E. Hampden, # Denver Orthodontist N/A Dr. Eunice P. Lee Hampden Family Dentistry $ Orthodontics Not Needed 9250 E. Hampden Ave Denver Orthodontist N/A Dr. Jack E. Duran Orthodontics Exlusively Not Needed 3601 S. Clarkson Englewood Orthodontist N/A Dr. T. Allan Hymas Mesa Orthodontics Not Needed 1190 Bookcliff, Ave., Ste Grand Junction Orthodontist N/A Dr. Gary Barth Dr. Gary Barth Not Needed th St. #a Greeley Orthodontist N/A Dr. David Richter Richter Orthodontics Not Needed st Ave Greeley Orthodontist N/A Dr. Shawn Murray Skyview Orthodontics Not Needed th Ave. #a Greeley Orthodontist N/A Dr. Bradley E. Goings Skyview Orthodontics Not Needed th Ave. #a Greeley Orthodontist N/A Dr. Paul A. Hamersky Douglas County Orthodontics Not Needed 4185 E. Wildcat Reserve Pkwy # Highlands Ranch Orthodontist N/A Dr. Bryan Nelson Dr. Bryan Nelson Not Needed 9567 S.University Blvd., #c-1a Highlands Ranch Orthodontist N/A Dr. Paul Rocke Dr. Paul Rocke Not Needed 200 W. County Line Rd. # Highlands Ranch Orthodontist N/A Dr. Shawn M. Murray Murray Orthodontics Not Needed 257 Johnstown Center Dr. # Johnstown Orthodontist N/A Dr. Howard Stringert Dr. Howard Stringert Not Needed 313 W. 3rd St., # La Junta Orthodontist N/A Dr. Jack Allen Jr. Dr. Jack M. Allen D.D.S. Not Needed 7373 W. Jefferson Ave. # Lakewood Orthodontist N/A Dr. Voytek Bobak Dr. Voytek Bobak Not Needed 1840 S. Wadsworth Blvd Lakewood Orthodontist N/A Dr. Michael D. Bellon Dr. Michael D. Bellon Not Needed 7325 S. Pierce St., # Littleton Orthodontist N/A Dr. Paul Rocke Front Range Orthodontic Not Needed 200 West County Line Rd., # Littleton Orthodontist N/A Dr. Amir R. Fereydouni Kids And Family Dentistry Not Needed 40 W. Littleton Blvd Littleton Orthodontist N/A Dr. Kurt Niepraschk Niepraschk Orthodontics Not Needed 9878 W. Belleview Ave Littleton Orthodontist N/A Dr. Eunice P. Lee Southpark Orthodontics Not Needed 8199 South Park Lane # Littleton Orthodontist N/A Dr. Fazila Durkin Durkin Orthodontics Not Needed 7430 Park Meadows Dr Lone Tree Orthodontist N/A Dr. Jonathan Weinbach Smile Zone Orthodontics Not Needed 1075 S. Boulder Rd., # Louisville Orthodontist N/A Dr. Shawn Murray Skyview Orthodontics Not Needed 2555 E. 13th St. # Loveland Orthodontist N/A Dr. Bradley E. Goings Skyview Orthodontics Not Needed 2555 E. 13th St. # Loveland Orthodontist N/A Dr. Andrey Nazarov Allegro Orthodontics Not Needed S. Progress Way # Parker Orthodontist N/A Dr. Howard Stringert Dr. Howard Stringert Not Needed 3955 Sandelwood Lane Pueblo Orthodontist N/A Dr. James H. Mason Colo Orthodontics Not Needed 3984 E. 120th Ave Thornton Orthodontist N/A Dr. James H. Mason Colo Orthodontics ti Not Needed d 901 E. 120th Ave. #e Thornton Orthodontist Oth ti t N/A Dr. John Bailey Colo Orthodontics Not Needed 3984 E. 120th Ave Thornton Orthodontist N/A Dr. John Bailey Colo Orthodontics Not Needed 901 E. 120th Ave. #e Thornton Orthodontist N/A Dr. Eunice P. Lee Kids And Family Dentistry And Orthodontics Not Needed 2300 E. 120th Ave. # Thornton Orthodontist N/A Dr. Colin Gibson 1st Impressions Orthodontics Not Needed 1333 W. 120th Ave. # Westminster Orthodontist N/A Dr. Jonathan Weinbach Smile Zone Orthodontics Not Needed 9910 Wadsworth Pkwy Westminster Orthodontist N/A Dr. David Richter Richter Orthodontics Not Needed 1218 W. Ash St Windsor Orthodontist N/A Page 9 of 10

21 Alpha and Choice Dental Plan including Orthodontists 10/28/2010 NAME OFFICE NAME PROVIDER # ADDRESS PHONE CITY SPECIALTY CODES bottom page General Provisions: Code Definitions: All needed specialty care (except Orthodontics) that cannot be provided by your selected General Dentist can be provided by a plan participating specialist. These specialists have been contracted to offer plan members up to a 20% discount off of their normal full fee. You may see any of the contracted plan specialists as the needed without contacting your selected General Dentist. Call us at or for a list of plan participating specialists or visit our web site at Orthodontic treatment discounts are listed on your plan schedule of benefits. All family members must see the same General Dentist for treatment. You may change your General Dentist selection at any time by contacting us at or * - This office provides nitrous oxide. C - This office accepts most children over the age of 4 for routine care. Please check with your selected dental office for their specific guidelines. E1-2 - This office will provide most 1 and 2 canal root canal procedures depending on the complexity of the situation. E3-4 - This office will provide most 3 and 4 canal root canal procedures depending on the complexity of the situation. Some large dental offices with multiple locations list all contracted providers from all locations combined. They do this because some of the providers float between offices as needed. Please contact the dental office for the specific providers at that location. N - This office will only see members that are identified on the eligibility roster provided by the plan administrative office at the beginning of each month. ** - Estos consultorios tienen personal de habla hispana. Page 10 of 10

22 OPTION #3 DENTAL INSURANCE PLAN To locate a Delta provider please visit: and click on the Provider Locator link the quick links box. Then go to the Delta logo and click. Select either PPO or Premier, enter your zip code and search parameters, and then click search for a dentist. Benefits provided by:

23 Plan A - Delta Dental Calendar Year Deductible $25 Deductible applies to Basic and Major services. Family deductible amount is three times the individual deductible. Annual Maximum Benefit $1,000 Per member, per calendar year. Prevention First (for PPO dentists) Included Diagnostic and Preventive services from PPO dentist do not count against annual maximum benefit. Dependent Age for Dental Benefits Age 26 Orthodontics Included? Optional If included: 50% coverage to age 19;; 12-month waiting period Orthodontic Lifetime Maximum $1,000 if included Network Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Participating Dentist Benefit Limitations Diagnostic & Preventive Services Oral Exams and Cleanings 100% 80% 80% Once each in a 6-month period Sealants 100% 80% 80% Once per tooth for permanent molars in children through age 14 in a 36-month period Bitewing 100% 80% 80% Once in a 12-month period Full Mouth X-Rays 100% 80% 80% Once in a 60-month period Fluoride 100% 80% 80% Once in a 12-month period, through age 15 Space Maintainers 100% 80% 80% Children through age 13 Basic Services Fillings 80% 80% 80% Once per tooth in a 24-month period, composite (white) fillings on front teeth only Simple Extractions 80% 80% 80% Major Services (12-month waiting period applies) Oral Surgery 50% 50% 50% Implants, Crowns (restorative phase) 50% 50% 50% Once per tooth in a 84-month period Dentures, Bridges 50% 50% 50% Only a benefit to replace a functioning, natural tooth that was extracted while the patient was covered under this plan Endodontics/Periodontics 50% 50% 50% Under the Delta Dental PPO plan, you may visit the dentist of your choice. There are three levels of dentists to choose from. PPO Dentist - Payment is based on the PPO dentist's allowable fee, or the actual fee charged, whichever is less. Premier Dentist - Payment is based on the PPO dentist's allowable fee, or the actual fee charged, whichever is less. Members are responsible for the difference between the PPO dentist's allowable fee and the Premier Maximum Plan Allowance fee. Non-Participating Dentist - Payment is based on the PPO dentist's allowable fee, or the actual fee charged, whichever is less. Members are responsible for the difference between the PPO dentist's allowable fee and the full fee charged by the dentist. You will receive the best benefit by choosing a PPO dentist. Enrollment type for these plans is Open Enrollment. Members can add dental coverage once per year. Benefit waiting periods apply, regardless of enrollment type. This is a brief description of services covered under your dental plan. Please refer to the Employee Benefit Booklet for full plan details. If differences exist between this summary and the Employee Benefit Booklet, the Employee Benefit Booklet will govern.

24 Delta Dental Premier, PPO Limitations and Exclusions - for Beta Health Plans The following is a brief summary of the benefit limitations and exclusions for the dental plan(s) quoted. Please refer to your dental contract for a complete list. Limitations on Type I Oral examinations and cleanings - once in any 6-month period Topical fluoride - once in 12 months under age 16. Bitewing x-rays once per 12 months. Sealants - once per tooth in any 36 consecutive month period under age 15. Full mouth x-rays - once per 60 months. Limitations on Type II Amalgam fillings - once per 24-month period. Limitations on Type IIIA Surgical Periodontic Services - once in any 36 month period. Non-Surgical Periodontic Services - once in any 24 month period. Periodontal cleanings are included in the cleaning limitations shown above. Reline or Rebase of a prosthodontic appliance will be once in any 36 month period. Limitations on Type IIIB Benefit for placement of Crowns and Onlays will not be provided more than once in any 84-month period involving restorations of the same tooth. Allowance for Crowns, Inlays, and Onlays posterior to the first molar will be limited to the allowance for a full metal restoration. The patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. Initial placement of full or partial Dentures is only a benefit to replace a natural tooth that was extracted while the patient was covered under this contract. Benefit for replacement is once per 60-month period if it cannot be repaired or made serviceab Initial placement of fixed bridges is only a benefit to replace a natural tooth that was extracted while the patient was covered under this contract. Benefit for replacement is once per 84-month period if it is not serviceable, and cannot be repaired. Limitations on Orthodontic Benefits (if covered) Replacement or repair of appliances is not covered. Orthodontic care provided in the treatment of periodontal cases or cases involving treatment or repositioning of the temporomandibular joint or related conditions is not covered. Periodic Orthodontic payments will end upon termination of treatment for any reason prior to completion of the case, or upon termination of the Covered Person s eligibility. For an Orthodontic treatment plan started prior to the eligibility date of the patient, Delta Dental will begin periodic payments with the first payment due following the patient eligibility date. The maximum benefit will be determined based upon the prio EXCLUSIONS The following Services are not Benefits: Any Covered Service Started when the person was not eligible for such Service under this Contract. Services for treatment of congenital (present at birth) or developmental (following birth) malformations, except intraoral dental Services for treatment of a condition which is related to, or developed as a result of, cleft lip and/or cleft palate. Services for cosmetic reasons. Services for restoring tooth structure lost from wear, erosion, attrition, abrasion or abfraction. Services related to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth due to improper alignment, occlusion or contour. Services related to periodontal stabilization of teeth. Habit appliances, night guards, occlusal guards, athletic mouth guards and gnathological (jaw function) Services, bite registration or analysis, or any related Services Charges for prescription drugs. Hospital costs and any additional fees charged by the Dentist or hospital for hospital services or visits, or charges for use of any facility. Any anesthesia service not specifically included in Covered Services. Orthodontic Services unless shown as covered on the Summary of Dental Plan Benefits. Myofunctional therapy or speech therapy. Services for the treatment of any disturbances of the temporomandibular joint (TMJ), facial pain or any related conditions. Oral hygiene instructions or dietary instructions. Replacement of lost, stolen or damaged appliances. Repair of appliances altered by someone other than a Dentist. Any Services including any associated Services or procedures not specifically included in Covered Services. Services for which charges would not have been made if this coverage had not existed, except for Services as provided under Medicaid.

25 Check out these Free National Discount Programs! All employees and dependents enrolling in one of the attached dental plans can use any of the attached programs free of charge. It is our thanks to you for using Beta Health as your dental provider! Simply follow the instructions on the attached discount program description sheets.it s that easy. You can photocopy these items and distribute to all of your dependents as well. If you have questions, please call Beta Health at or

26 Introducing Discount Services for Dental Plan Members Free of Charge The Vision Discount Plan Beta Health Association, Inc. has teamed up with EyeMed Vision Care to offer easy access to over 43,000 national, conveniently located vision care providers including optometrists, ophthalmologists, opticians and many leading optical retailers, such as LensCrafters, Target Optical, and most Sears Optical and Pearl Vision locations. This benefit is free of charge for Beta Health Dental Plan members. Note that this is not insurance, only a discount plan to save you and your family members $ as needed! Vision Care Services Exam with Dilation (as necessary) Contact Lens Fit and Follow-up Standard Premium In Network Only $5 off exam $10 off exam $10 off exam Frames When a complete pair of glasses is purchased (frame, lenses and lens options purchased in the same transaction) a 35% discount will apply.* Standard Plastic Lenses Member Pays Single Vision $50 Bifocal $70 Trifocal $105 Lens Options Member Pays UV Coating $15 Tint (Solid and Gradient) $15 Standard Scratch Resistant Coating $15 Standard Polycarbonate $40 Standard Anti-Reflective Coating $45 Standard Progressive (Add-on to Bifocal) $65 Other Add-ons and Services 20% off retail Contact Lens Materials (Discount applied to materials only) Conventional 15% off retail price Disposable no discount Laser Vision Correction** Lasik or PRK Frequency Examination Frame Lenses or Contact Lenses 15% off retail price or 5% promotional price Unlimited Unlimited Unlimited * Items purchased separately will be discounted 20% off of the retail price. ** Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call LASER6.

27 Introducing Discount Services for Dental Plan Members Free of Charge The Hearing Discount Plan This hearing care program combines unlimited choices with quality and value. It s provided free of charge to all employees and family members enrolled in a Beta Health Association, Inc. dental plan. Beta Health and EPIC Hearing Health Care give you easy access to a large national network of thousands of hearing care professionals primarily physicians and audiologists who can help you achieve your maximum hearing potential throughout your life. The prices you get from EPIC may be as much as 50% below the manufacturer s suggested retail price and up to 35% lower than most discount offers. EPIC can coordinate the coverage with your existing healthcare plan. Note that this is not insurance, only a discount plan to save you and your family members $ as needed! To activate your hearing discount plan, call EPIC Hearing Health at EPIC will send you a card with all the information you need to access your benefits, including referrals to providers near you and activation forms to access them. Tell them that you are a Beta Health member and you will be connected to a personal EPIC phone contact who can answer any questions you may have. A booklet that outlines the plan benefits (as well as pricing) will be mailed to your home. Then you will follow through with an appointment, examination and treatment. All payments should be made to EPIC HSP. No other billing or payments should occur. Contact EPIC at any time for assistance, advice and information. Check out these benefits and savings! The hearing discount plan benefits and savings are: Hearing tests Hearing aids, aid cleaning supplies, accessories and batteries Ear protection, swim and musician earplugs Assistive listening devices TV ears (amplifies and clarifies television) Alerting and signaling devices The Prescription Drug Discount Plan Do you want to SAVE an average of 10% to 85% on the cost of prescription medications? With the HealthTrans nationwide national discount prescription drug program this is easy! It s simply a great way to save money on prescription drugs! After working closely with pharmacies and drug manufacturers, HealthTrans has negotiated lower prices for thousands of medications, and have passed these savings on to all Beta Health Association members and their families. The average discounts range from up to 16% on brand name and up to 55% on generic drugs. There are no limits on quantities and no paperwork to complete. Discounts are available at over 55,000 pharmacies nationwide and are also available to the entire family on an as needed basis! To use your HealthTrans discount drug card: 1.) Write in your specific member I.D. number on the member I.D. cards (attached) for use at the pharmacy. 2.) Take your card and prescription(s) to a participating pharmacy. Pharmacy locations can be found at the web site below. 3.) Pay the pharmacy the negotiated reduced discount! Note that this is not insurance, only a discount plan to save you and your family members $ as needed! See how much you can save today by going to

28 Thank you for choosing Beta Health Association, Inc. as your dental partner. We are proud to offer you, free of charge, the EyeMed Vision Discount Plan, the Epic Hearing Health Plan and the HealthTrans Prescription Discount Plan. Please use the ID cards provided below to access these Free of Charge benefits. Follow all instructions as identified on each set of cards. We appreciate our relationship! EyeMed Group Number: Group Name: Beta Health Association, Inc. Member Name: EyeMed Group Number: Group Name: Beta Health Association, Inc. Member Name: Call to locate the nearest EyeMed Provider. This is a discount program and not insurance. Call to locate the nearest EyeMed Provider. This is a discount program and not insurance. Epic Hearing: Call for ID card information. Group Name: Beta Health Association, Inc. Member Name: Epic Hearing: Call for ID card information. Group Name: Beta Health Association, Inc. Member Name: This is a discount program and not insurance. This is a discount program and not insurance. BIN #: Group ID: DDS01 Member ID: Please enter your initials & the last four digits of your phone #) Member Name: This is a discount program and not insurance. Visit for more information or call BIN #: Group ID: DDS01 Member ID: Please enter your initials & the last four digits of your phone #) Member Name: This is a discount program and not insurance. Visit for more information or call

29 COMBINED DENTAL EMPLOYEE ENROLLMENT FORM Please complete the form following this page and submit to personnel at your earliest convenience. Note that since this is an annual open enrollment, all employees must either enroll or waive for the next year. A REMINDER! You will not be allowed to enroll in any plans again until this time next year.

30