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1 Plan Benefit Highlights for: UNIVERSITY OF SOUTHERN CALIFORNIA STUDENT PLAN Group No: The Delta Dental PPO table plan provides you great dental benefits at a reasonable cost. With a table of allowance plan, you know in advance exactly how much the plan covers for each dental service. Just refer to the table of allowances listed inside to see how much the plan covers for each dental service. You are responsible for the share of the dentist s fee not covered by the allowance.* The table of allowance plan allows you the freedom to visit any licensed dentist, including a dentist from our Delta Dental Premier network. However, there are advantages to visiting a PPO network dentist instead of a Premier or non-delta Dental dentist: Since PPO dentists agree to accept reduced fees, you will usually pay a lower amount for services when you visit a Delta Dental PPO dentist. If you can t visit a PPO network dentist, a Premier dentist may still be able to save you money on out-of pocket costs. With either network, you ll only be responsible for the difference between Delta Dental s table allowance and the dentist s approved amount.* Non- Delta Dental dentists may balance bill you up to their entire submitted amount.** SM Delta Dental offers you what no other dental plan can The Delta Dental Difference. Here s what makes us a leading provider of dental benefits: Exceptional Cost Savings Our networks protect enrollees from balance billing and prevent dentists from charging more by unbundling services that should be billed as one service. Your costs are usually lowest when you visit a Delta Dental PPO dentist. Guaranteed Coinsurance/Copayment Delta Dental dentists agree to accept our determination of fees. They won t balance bill over Delta Dental s approved amount. Professional Treatment Standards Delta Dental reviews utilization patterns and office practices to ensure that Delta Dental dentists meet professional standards for safety and quality of care. Patient s share also includes any remaining deductible, any amount over the annual maximum and any services your plan does not cover. ** If you visit a non-delta Dental dentist, we will send Delta Dental's share of the table allowance directly to you. You are responsible for paying the non-delta Dental dentist's total fee. Eligibility Deductibles Deductibles waived for D & P? Maximums Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26 $50 per person / $150 per family each plan year Yes $1,200 per person each plan year Delta Dental of California 100 First St. San Francisco, CA Customer Service Claims Address P.O. Box Sacramento, CA deltadentalins.com/usc The information contained herein is not intended or designed to replace or serve as an Evidence of Coverage or Summary Plan Description for the program. If you have specific questions regarding benefit structure, limitations or exclusions, consult your company s benefits representative. HLT_PPO_TBL_DDC (Rev. #2 5/13)_lu.06/2013

2 Diagnostic 0120 Periodic oral evaluation -- established patient $ Limited oral evaluation -- problem focused $ * Comprehensive oral evaluation -- new or established patient, by report $ 23* 0160 Detailed and extensive oral evaluation, problem focused, by report $ Reevaluation limited problem focused (established patient; not post operative visit) $ Comprehensive periodontal evaluation -- new or established patient $ 24* 0210* Intraoral -- complete series (including bitewings) $ 47* 0220 Intraoral -- periapical first film $ Intraoral -- periapical each additional film $ Intraoral -- occlusal film $ Extraoral -- first film $ Extraoral -- each additional film $ Bitewing -- single film $ Bitewings -- two films $ * Bitewings -- four films $ 20* 0277 Vertical bitewings -- 7 to 8 films $ Posterior -- anterior or lateral skull and facial bone survey film $ Panoramic film $ Cephalometric film $ Pulp vitality tests $ Diagnostic casts $ Consultation -- diagnostic service provided by dentist or physician other than requesting dentist or physician $ 15 Preventive 1110* Prophylaxis -- adult $ 33* 1120 Prophylaxis -- child through age 13 $ Topical application of fluoride - child $ Topical application of fluoride - adult $ Topical fluoride varnish; therapeutic application for moderate to high caries risk patients $ Sealant -- per tooth $ Preventive resin restoration in a moderate to high caries risk patient permanent tooth $ Space maintainer -- fixed -- unilateral $ Space maintainer -- fixed -- bilateral $ Space maintainer -- removable -- unilateral $ Space maintainer -- removable -- bilateral $ Recementation of space maintainer $ 19 Restorative 2140 Amalgam -- one surface, primary or permanent $ Amalgam -- two surfaces, primary or permanent $ Amalgam -- three surfaces, primary or permanent $ Amalgam -- four or more surfaces, primary or permanent $ Resin-based composite -- one surface, anterior $ Resin-based composite -- two surfaces, anterior $ Resin-based composite -- three surfaces, anterior $ Resin-based composite -- four or more surfaces or involving incisal angle (anterior) $ Resin-based composite crown, anterior $ Resin-based composite -- one surface, posterior $ Resin-based composite -- two surfaces, posterior $ 56 *Members who visit the USC School of Dentistry or the USC Oral Health Care Center will have an increased fee allowance applied to the following procedures: 0150* Comprehensive oral evaluation -- new or established patient, by report $65* 0180* Comprehensive periodontal evaluation -- new or established patient $65* 0210* Intraoral -- complete series (including bitewings) $90* 0274* Bitewings -- four films $30* 1110* Prophylaxis -- adult $75* 4341* Periodontal scaling and root planing -- four or more contiguous teeth or bounded teeth spaces per quadrant $90* 2

3 Restorative 2393 Resin-based composite -- three surfaces, posterior $ Resin-based composite -- four or more surfaces, posterior $ 78 Endodontics 3220 Therapeutic pulpotomy (excluding final restoration) -- removal of pulp coronal to the dentinocemental junction and application of medicament $ Pulpal debridement, primary and permanent teeth $ Pulpal therapy (resorbable filling) -- anterior, primary tooth (excluding final restoration) $ Pulpal therapy (resorbable filling) -- posterior, primary tooth (excluding final restoration) $ Endodontic therapy, anterior tooth (excluding final restoration) $ Endodontic therapy, bicuspid tooth (excluding final restoration) $ Endodontic therapy, molar tooth (excluding final restoration) $ Treatment of root canal obstruction; non-surgical access $ Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $ Internal root repair of perforation defects $ Retreatment of previous root canal therapy -- anterior $ Retreatment of previous root canal therapy -- bicuspid $ Retreatment of previous root canal therapy -- molar $ Apicoectomy/periradicular surgery -- anterior $ Apicoectomy/periradicular surgery -- bicuspid (first root) $ Apicoectomy/periradicular surgery -- molar (first root) $ Apicoectomy/periradicular surgery (each additional root) $ Retrograde filling -- per root $ Root amputation -- per root $ Hemi section (including any root removal), not including root canal therapy $ 37 Periodontics 4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $ Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $ Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant $ Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant $ Apically positioned flap $ Clinical crown lengthening -- hard tissue $ Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $ Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant $ Bone replacement graft -- first site in quadrant $ Bone replacement graft -- each additional site in quadrant $ Biologic materials to aid in soft and osseous tissue regeneration $ Guided tissue regeneration -- resorbable barrier, per site $ Guided tissue regeneration -- non-resorbable barrier, per site (includes membrane removal) $ Pedicle soft tissue graft procedure $ Free soft tissue graft procedure (including donor site surgery) $ Subepithelial connective tissue graft procedures, per tooth $ Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $ Soft tissue allograft $ Combined connective tissue and double pedicle graft, per tooth $ * Periodontal scaling and root planing -- four or more contiguous teeth or bounded teeth spaces per quadrant $ 40* 4342 Periodontal scaling and root planing -- one to three teeth, per quadrant $ Full mouth debridement to enable comprehensive evaluation and diagnosis $ Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $ Periodontal maintenance (following active therapy) $ Unscheduled dressing change (by someone other than treating dentist) $ 5 3

4 Oral Surgery 7111 Extraction, coronal remnants -- deciduous tooth $ Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $ Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $ Removal of impacted tooth -- soft tissue $ Removal of impacted tooth -- partially bony $ Removal of impacted tooth -- completely bony $ Removal of impacted tooth -- completely bony, with unusual surgical complications $ Surgical removal of residual tooth roots (cutting procedure) $ Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $ Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $ Surgical access of an unerupted tooth $ Mobilization of erupted or malpositioned tooth to aid eruption $ Surgical repositioning of teeth $ Alveoloplasty in conjunction with extractions -- four or more teeth or tooth spaces, per quadrant $ Alveoloplasty not in conjunction with extractions -- four or more teeth or tooth spaces, per quadrant $ Removal of benign odontogenic cyst or tumor -- lesion diameter up to 1.25 cm $ Removal of benign odontogenic cyst or tumor -- lesion diameter greater than 1.25 cm $ Surgical reduction of osseous tuberosity $ Incision and drainage of abscess -- intraoral soft tissue $ Incision and drainage of abscess -- extraoral soft tissue $ Frenulectomy (frenectomy or frenotomy) -- separate procedure $ Excision of hyperplastic tissue -- per arch $ Excision of pericoronal gingival $ Surgical reduction of fibrous tuberosity $ Synthetic graft -- mandible or facial bones, by report $ 61 Prosthodontics 2510 Inlay -- metallic -- one surface $ Inlay -- metallic -- two surfaces $ Inlay -- metallic -- three or more surfaces $ Onlay -- metallic -- two surfaces $ Onlay -- metallic -- three surfaces $ Onlay -- metallic -- four or more surfaces $ Inlay -- porcelain/ceramic -- one surface $ Inlay -- porcelain/ceramic -- two surfaces $ Inlay -- porcelain/ceramic -- three or more surfaces $ Onlay -- porcelain/ceramic -- two surfaces $ Onlay -- porcelain/ceramic -- three surfaces $ Onlay -- porcelain/ceramic -- four or more surfaces $ Inlay -- resin-based composite -- one surface $ Inlay -- resin-based composite -- two surfaces $ Inlay -- resin-based composite -- three or more surfaces $ Onlay -- resin-based composite -- two surfaces $ Onlay -- resin-based composite -- three surfaces $ Onlay -- resin-based composite -- four or more surfaces $ Crown -- resin-based composite (indirect) $ Crown -- resin with high noble metal $ Crown -- resin with predominantly base metal $ Crown -- resin with noble metal $ Crown -- porcelain/ceramic substrate $ Crown -- porcelain fused to high noble metal $200 4

5 Prosthodontics 2751 Crown -- porcelain fused to predominantly base metal $ Crown -- porcelain fused to noble metal $ Crown -- 3/4 cast high noble metal $ Crown -- 3/4 cast predominantly base metal $ Crown -- 3/4 cast noble metal $ Crown -- 3/4 porcelain/ceramic $ Crown -- full cast high noble metal $ Crown -- full cast predominantly base metal $ Crown -- full cast noble metal $ Recement inlay, onlay, or partial coverage restoration $ Recement crown $ Prefabricated stainless steel crown -- primary tooth $ Prefabricated stainless steel crown -- permanent tooth $ Prefabricated resin crown $ Prefabricated stainless steel crown with resin window $ Prefabricated esthetic coated stainless steel crown -- primary tooth $ Core buildup, including any pins $ Pin retention -- per tooth, in addition to restoration $ Post and core in addition to crown, indirectly fabricated $ Each additional indirectly fabricated post - same tooth $ Prefabricated post and core in addition to crown $ Post removal (not in conjunction with endodontic therapy) $ Each additional prefabricated post - same tooth $ Labial veneer (resin laminate) -- chair side $ Labial veneer (resin laminate) -- laboratory $ Labial veneer (porcelain laminate) -- laboratory $ Temporary crown (fractured tooth) $ Crown repair, by report $ Complete denture -- maxillary $ Complete denture -- mandibular $ Immediate denture -- maxillary $ Immediate denture -- mandibular $ Maxillary partial denture -- resin base (including any conventional clasps, rests and teeth) $ Mandibular partial denture -- resin base (including any conventional clasps, rests and teeth) $ Maxillary partial denture -- cast metal framework with resin denture bases (including conventional clasps, rests and teeth) $ Mandibular partial denture -- cast metal framework with resin denture bases (including conventional clasps, rests and teeth) $ Removable unilateral partial denture -- one piece cast metal (including clasps and teeth) $ Adjust complete denture -- maxillary $ Adjust complete denture -- mandibular $ Adjust partial denture -- maxillary $ Adjust partial denture -- mandibular $ Repair broken complete denture base $ Replace missing or broken teeth -- complete denture (each tooth) $ Repair resin denture base (partial) $ Repair cast framework (partial) $ Repair or replace broken clasp $ Replace broken teeth -- per tooth $ Add tooth to existing partial denture $ Add clasp to existing partial denture $ Replace all teeth and acrylic on cast metal framework (maxillary) $ Replace all teeth and acrylic on cast metal framework (mandibular) $ Rebase complete maxillary denture $ 75 5

6 Prosthodontics 5711 Rebase complete mandibular denture $ Rebase maxillary partial denture $ Rebase mandibular partial denture $ Reline complete maxillary denture (chair side) $ Reline complete mandibular denture (chair side) $ Reline maxillary partial denture (chair side) $ Reline mandibular partial denture (chair side) $ Reline complete maxillary denture (laboratory) $ Reline complete mandibular denture (laboratory) $ Reline maxillary partial denture (laboratory) $ Reline mandibular partial denture (laboratory) $ Interim partial denture (maxillary) $ Interim partial denture (mandibular) $ Tissue conditioning, maxillary $ Tissue conditioning, mandibular $ Overdenture -- complete -- by report $ Overdenture -- partial -- by report $ Modification of removable prosthesis following implant surgery $ Surgical placement of implant body: endosteal implant $ Surgical placement of interim implant body for transitional prosthesis: endosteal implant $ Surgical placement: eposteal implant $ Surgical placement: transosteal implant $1, Implant removal, by report $ Implant/abutment supported removable denture for completely edentulous arch $ Implant/abutment supported removable denture for partially edentulous arch $ Dental implant supported connecting bar $ Prefabricated abutment -- includes placement $ Custom abutment -- includes placement $ Abutment supported porcelain/ceramic crown $ Abutment supported porcelain fused to metal crown (high noble metal) $ Abutment supported porcelain fused to metal crown (predominantly base metal) $ Abutment supported porcelain fused to metal crown (noble metal) $ Abutment supported cast metal crown (high noble metal) $ Abutment supported cast metal crown (predominantly base metal) $ Abutment supported cast metal crown (noble metal) $ Implant supported porcelain/ceramic crown $ Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $ Implant supported metal crown (titanium, titanium alloy, high noble metal) $ Abutment supported retainer for porcelain/ceramic FPD $ Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $ Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $ Abutment supported retainer for porcelain fused to metal FPD (noble metal) $ Abutment supported retainer for cast metal FPD (high noble metal) $ Abutment supported retainer for cast metal FPD (predominantly base metal) $ Abutment supported retainer for cast metal FPD (noble metal) $ Implant supported retainer for ceramic FPD $ Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) $ Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $ Implant/abutment supported fixed denture for completely edentulous arch $ Implant/abutment supported fixed denture for partially edentulous arch $ Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis $ Repair implant supported prosthesis, by report $ 76 6

7 Prosthodontics 6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment $ Recement implant/abutment supported crown $ Recement implant/abutment supported fixed partial denture $ Repair implant abutment, by report $ Abutment supported crown -- (titanium) $ Pontic -- cast high noble metal $ Pontic -- cast predominantly base metal $ Pontic -- cast noble metal $ Pontic -- porcelain fused to high noble metal $ Pontic -- porcelain fused to predominantly base metal $ Pontic -- porcelain fused to noble metal $ Pontic -- porcelain/ceramic substrate $ Pontic -- resin with high noble metal $ Pontic -- resin with predominantly base metal $ Pontic -- resin with noble metal $ Retainer -- cast metal for resin bonded fixed prosthesis $ Retainer -- porcelain/ceramic for resin bonded fixed prosthesis $ Inlay -- porcelain/ceramic, two surfaces $ Inlay -- porcelain/ceramic, three or more surfaces $ Inlay -- cast high noble metal, two surfaces $ Inlay -- cast high noble metal, three or more surfaces $ Inlay -- cast predominantly base metal, two surfaces $ Inlay -- cast predominantly base metal, three or more surfaces $ Inlay -- cast noble base metal, two surfaces $ Inlay -- cast noble base metal, three or more surfaces $ Onlay -- porcelain/ceramic, two surfaces $ Onlay -- porcelain/ceramic, three or more surfaces $ Onlay -- cast high noble metal, two surfaces $ Onlay -- cast high noble metal, three or more surfaces $ Onlay -- cast predominantly base metal, two surfaces $ Onlay -- cast predominantly base metal, three or more surfaces $ Onlay -- cast noble metal, two surfaces $ Onlay -- cast noble metal, three or more surfaces $ Crown -- resin with high noble metal $ Crown -- resin with predominantly base metal $ Crown -- resin with noble metal $ Crown -- porcelain/ceramic $ Crown -- porcelain fused to high noble metal $ Crown -- porcelain fused to predominantly base metal $186 Other 6752 Crown -- porcelain fused to noble metal $ Crown -- 3/4 cast high noble metal $ Crown -- 3/4 cast predominantly base metal $ Crown -- 3/4 cast noble metal $ Crown -- 3/4 porcelain/ceramic $ Crown -- full cast high noble metal $ Crown -- full cast predominantly base metal $ Crown -- full cast noble metal $ Connector bar $ Recement fixed partial denture $ Prefabricated post and core in addition to fixed partial denture retainer $ 44 7

8 Other 6973 Core buildup for retainer, including any pins $ Coping -- metal $ Each additional indirectly fabricated post -- same tooth $ Each additional prefabricated post -- same tooth $ Fixed partial denture repair, by report $ Palliative (emergency) treatment of dental pain -- minor procedure $ Deep sedation/general anesthesia -- first 30 minutes $ Deep sedation/general anesthesia -- each additional 15 minutes $ Analgesia, anxiolysis, inhalation of nitrous oxide $ Office visit for observation (during regularly scheduled hours) -- no other services performed $ Office visit -- after regularly scheduled hours $ Case presentation, detailed and extensive treatment planning $ Treatment of complications (post-surgical) -- unusual circumstances, by report $ Occlusal guard, by report $ Occlusal adjustment -- limited $ Occlusal adjustment -- complete $116 NOTE: PROCEDURE CODES NOT INCLUDED IN THE ABOVE SCHEDULE OF ALLOWANCES ARE NOT A COVERED BENEFIT. Rev.06/13 8

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