Page 66 - APPENDICES for Fred Falten

Fluoride treatment

Not covered

Dental x-rays
Covered under o ce visit

Limits apply

COMPREHENSIVE DENTAL

Non-routine services
In-network: $50 copay or 50% coinsurance

Limits apply

Diagnostic services
In-network: $50 copay or 50% coinsurance

Limits apply

Restorative services
In-network: $50 copay or 50% coinsurance

Limits apply

Endodontics

In-network: $50 copay or 50% coinsurance
Limits apply

Periodontics
In-network: $50 copay or 50% coinsurance

Limits apply

Extractions
In-network: $50 copay or 50% coinsurance

Limits apply

Prosthodontics, other oral/maxillofacial surgery, other services
In-network: $50 copay or 50% coinsurance