INSURANCE BENEFITS Chart#2944 Enrollee Name: Diana Baltazar Patient Name: Self Date of Birth:12/15/1982 Program Type: Delta Dental PPO Enrollee ID: 2205623201 P.0 Box 997330 Plan Name: UC! HealthCare ‘Sacramento, CA 95899 Plan Number: 0256955 (800)335-8227 Effective Date: 01/01/2016 BENEFIT YEAR : CALENDAR YEAR PREV. BASIC MAJOR INS, 00% 80% 50% zl DED. $2500 FAM 75.00, MAX, $ 1500 MAXUSED | $0usedas of 5/19/2016 WAITINGPERIOD : NO PRIOR XB'S : NO AUTHO : SUG OVER $ 500 ENDO:80% ORALSURG:80% — PERIO:80% © PFMS0% © POST:50% Crown Length: 80% Open & Med:80% Denture replacement: 1/60MO PFMIBB Replacement: 1/60MO Posterior composite: Yes seals: imitation Age Tooth Code Benefit is limited to once per non-carious tooth within a Child to age 16 03, 14, 19, 30 36Months. Benefit is limited to once per non-carious tooth within a Child to age 16 02, 15, 18, 31 36months. FREQUENCY FX: 1/36M0 BW Adult PY Exam: 2PY —_Prophy: JPY Fluoride: 4/PY up to age 15 Perio tx. (4341): 1/24M0 2 Quads per visit. PERIO CHART & X-RAYS NO HISTORY FNK: BW. PERIOTX: EXAMIPROPHY: SealantliX : : . BB: 5 2 . . . . Crown: : z - . . Endo: ; z : . . ‘COMMENTS: D4955 Full Mouth Debridement: 80% Coverage 4310 Periodontal Maintenance: 60% Coverage PY Payor: 77777 SPOKETO: online benefit & eligibility performed 5119/2016 zy] aN FEB] WAR | APR | WAY | JUN | JUL | AUG | SEP | OCT | NOV DEC i 6 Zz) aan Fes | WAR | APR | MAY | JUN | JUL | AUG | SEP | OCT |. NOV DEC 4 6 o | a) aw FEB | WAR | APR | MAY | JUN | JUL | AUG | SEP | OCT | NOV DEC i" | 7 | 2) aN FEB | WAR | APR | MAY | JUN | JUL | AUG | SEP | OCT | NOV DEC 1 | 7