Page 58 - APPENDICES for Vic Bosiger

COMPREHENSIVE DENTAL

Care to maintain or treat problems with your teeth and gums.

Non-routine services $25 copay Limits apply

Diagnostic services $25 copay Limits apply

Restorative services $25 copay Limits apply

Endodontics $25 copay Limits apply

Periodontics $25 copay Limits apply

Extractions $25 copay Limits apply

Prosthodontics, other $25 copay Limits apply
oral/maxillofacial surgery,
& other services