Page 92 - 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
Out-of-network: $50 copay or
50-75% coinsurance

Diagnostic services In-network: $50 copay or 50% Limits apply
coinsurance
Out-of-network: $50 copay or
50-75% coinsurance

Restorative services In-network: $50 copay or 50% Limits apply
coinsurance
Out-of-network: $50 copay or
50-75% coinsurance

Endodontics In-network: $50 copay or 50% Limits apply
coinsurance
Out-of-network: $50 copay or
50-75% coinsurance

Periodontics In-network: $50 copay or 50% Limits apply
coinsurance
Out-of-network: $50 copay or
50-75% coinsurance

Extractions In-network: $50 copay or 50% Limits apply
coinsurance
Out-of-network: $50 copay or
50-75% coinsurance

Prosthodontics, other In-network: $50 copay or 50% Limits apply
oral/maxillofacial surgery, coinsurance
& other services Out-of-network: $50 copay or
50-75% coinsurance