Page 61 - Appendices for Eric Hartman

COMPREHENSIVE DENTAL

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

Non-routine services $0-125 copay Limits apply

Diagnostic services $0-5 copay Limits apply

Restorative services $8-395 copay Limits apply

Endodontics $5-395 copay Limits apply

Periodontics $0-380 copay Limits apply

Extractions $0-140 copay Limits apply

Prosthodontics, other $13-395 copay Limits apply
oral/maxillofacial surgery,
& other services