Page 65 - APPENDICES for Janet Tuma
P. 65
Fitting/evaluation
$0 copay
Limits apply
Hearing aids - All types
$199-499 copay
Limits apply
PREVENTIVE DENTAL
Oral exam
$0 copay
Limits apply
Cleaning
$0 copay
Limits apply
Fluoride treatment
Not covered
Dental x-rays
$0 copay
Limits apply
COMPREHENSIVE DENTAL
Non-routine services
Not covered
Diagnostic services
Not covered
Restorative services
