Page 57 - APPENDICES for Neill McLauchlin

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

Limits apply

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

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: 30% coinsurance

Limits apply

Contact lenses
In-network: $0 copay

Out-of-network: $0 copay

Limits apply

Eyeglasses (frames & lenses)