Page 50 - APPENDICES for Janet Tuma
P. 50
Diagnostic services
Not covered
Restorative services
$0 copay
Limits apply
Endodontics
Not covered
Periodontics
$0 copay
Limits apply
Extractions
$0 copay
Limits apply
Prosthodontics, other oral/maxillofacial surgery, other services
$0 copay
Limits apply
VISION
Routine eye exam
$0 copay
Limits apply
Contact lenses
$0 copay
Limits apply
Eyeglasses (frames & lenses)
$0 copay
Limits apply
