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Exhibit B <br />Delta Dental PPO plus Premier <br />Summary of Dental Plan Benefits <br />For Group# 8702-0001, 0999 <br />Orange County <br />This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental <br />Care Certificate will provide you with additional information about your Delta Dental plan, including information <br />about plan exclusions and limitations. The percentages below will be applied to the lesser of the dentist's submitted <br />fee and Delta Dental's allowance for each service. Delta Dental's allowance may vary by the dentist's network <br />participation. PLEASE NOTE - If you choose a Nonparticipating Dentist, you will be responsible for any difference <br />between the amount Delta Dental allows and the amount the Nonparticipating Dentist charges, in addition to any <br />Copayment or Deductible. <br />Control Plan -De lta Dental of North Carolina <br />Benefit Year - January 1 through December 31 <br />Covered Services - <br />Non- <br />Premier Dentist participating <br />Dentist <br />Plan Pays Plan Pays* <br />Diagnostic and Preventive Services - includes exams, ,~UO°1a 100%0 100% <br />cleanin s, fluoride, and s ace maintainers <br />Emergency Palliative Treatment - to temporarily ~~jpo~ 100% <br /> <br />relieve ain a 100% <br />Sealants - to revent decay of ermanent teeth 1QQ fo ' 100% 100% <br />Brush Bio sy - to detect oral cancer '.1b0% 100% 100% <br />Radio ra hs - X-ra s =:10~°~0 , ~ ~~ 100% ~ 100% <br />Periodontal Maintenance - cleanin s b a specialist ;.~ , ~ i~D°~o ~~~ 100% ~~~ ~~~ 100% <br />e <br />Minor Restorative Services - fillin s and crown re air " $5°l 85%' ' 85% <br />Endodontic Services - root canals $5% 85% 85% <br />Periodontic Services - to treat um disease 8S°/u ' 85% 85% <br />Oral Sur e Services - extractions and dental sur er 85°10 . 85% ' 85% <br />Other Basic Services - misc. services 85% . 85% 85°/a <br />Ma'or Restorative Services - crowns " SU°/a 50%' ` 50% <br />Relines and Re airs - to brid es and dentures 50°~'0 ; 50% 50% <br />Prosthodontic Services - includes bridges, implants S~dJa 50% 50% <br />and dentures <br />~ Orthodontic Services - includes braces 50°/a ; 50% 50% <br />~ Orthodontic Age Limit - ~'No A~e:Lirtiit ~-_ ~ No Aee Limit No Aee Limit <br />* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of <br />Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee <br />may be less than what your dentist charges, which means that you will be responsible for the difference. <br />- Oral exams (including evaluations by a specialist) are payable twice per calendar year. <br />- Prophylaxes (cleanings) are payable twice per calendar year. <br />Customer Service Toll-Free Number: 800-524-0149 <br />www. DeltaDentalNC. com <br />October 25, 2011 <br />