Page 32 - APPENDICES for Janet Tuma

In-network: $0 copay
Out-of-network: 30% coinsurance

Limits apply

Fluoride treatment
Not covered

Dental x-rays
In-network: $0 copay

Out-of-network: 30% coinsurance
Limits apply

COMPREHENSIVE DENTAL

Non-routine services
In-network: 20% coinsurance
Out-of-network: 50-70% coinsurance

Limits apply

Diagnostic services
Not covered

Restorative services
In-network: 20-50% coinsurance
Out-of-network: 50-70% coinsurance

Limits apply

Endodontics

In-network: 20% coinsurance
Out-of-network: 50-70% coinsurance

Limits apply

Periodontics
In-network: 20% coinsurance

Out-of-network: 50-70% coinsurance

Limits apply