Page 49 - APPENDICES for Diane Falten

COMPREHENSIVE DENTAL

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

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

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

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

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

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

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

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