Page 66 - Appendices to Donald Pender's Evaluation

PREVENTIVE DENTAL

Care to prevent or nd problems with your teeth and gums.

Oral exam $0 copay Limits apply

Cleaning $0 copay Limits apply

Fluoride treatment $0 copay Limits apply

Dental x-rays $0 copay Limits apply

COMPREHENSIVE DENTAL

Care to maintain or treat problems with your teeth and gums.

Non-routine services $0 copay Limits apply

Diagnostic services $0 copay Limits apply

Restorative services $20-350 copay Limits apply

Endodontics $15-295 copay Limits apply

Periodontics $15-375 copay Limits apply

Extractions $25-140 copay Limits apply

Prosthodontics, other $20-425 copay Limits apply
oral/maxillofacial surgery,
& other services