Page 80 - APPENDICES for Vic Bosiger

HEARING

Hearing exam In-network: $35 copay Limits apply
Out-of-network: 40%
coinsurance

Fitting/evaluation In-network: $0 copay Limits apply
Out-of-network: $0 copay

Hearing aids - all types In-network: $399-699 copay Limits apply

Out-of-network: $399-699
copay

PREVENTIVE DENTAL

Care to prevent or nd problems with your teeth and gums.

Oral exam In-network: $0 copay Limits apply
Out-of-network: $0 copay

Cleaning In-network: $0 copay Limits apply

Out-of-network: $0 copay

Fluoride treatment In-network: $0 copay Limits apply
Out-of-network: $0 copay

Dental x-rays In-network: $0 copay Limits apply
Out-of-network: $0 copay