Page 92 - Appendices to Jane Miller's evaluation
P. 92

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




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