Page 34 - APPENDICES for Vic Bosiger
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COMPREHENSIVE DENTAL
Care to maintain or treat problems with your teeth and gums.
Non-routine services Not covered
Diagnostic services In-network: $0 copay Limits apply
Out-of-network: $0 copay
Restorative services In-network: $0 copay Limits apply
Out-of-network: $0 copay
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other In-network: $0 copay Limits apply
oral/maxillofacial surgery, Out-of-network: $0 copay
& other services
