Page 93 - Appendices to Jane Miller's evaluation

Limits apply

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

Limits apply

Extractions
In-network: $0 copay

Out-of-network: $0 copay

Limits apply

Prosthodontics, other oral/maxillofacial surgery, other services
In-network: $0 copay

Out-of-network: $0 copay
Limits apply

VISION

Routine eye exam

In-network: $0 copay
Out-of-network: 40% coinsurance

Limits apply

Contact lenses
Not covered

Eyeglasses (frames & lenses)

Not covered

Eyeglass frames (only)
Not covered

Eyeglass lenses (only)
Not covered