Page 78 - Appendices to Jane Miller's evaluation

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

Limits apply

Cleaning

In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Fluoride treatment

In-network: $0 copay
Out-of-network: $0 copay

Limits apply

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

Limits apply

COMPREHENSIVE DENTAL

Non-routine services

In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Diagnostic services
In-network: $0 copay

Out-of-network: $0 copay

Limits apply

Restorative services
In-network: $0 copay
Out-of-network: $0 copay

Limits apply