Page 84 - Appendices to Donald Pender's Evaluation

COMPREHENSIVE DENTAL

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

Non-routine services Not covered

Diagnostic services $0-16 copay Limits apply

Restorative services $19-430 copay Limits apply

Endodontics $25-373 copay Limits apply

Periodontics $40-80 copay Limits apply

Extractions $23-80 copay Limits apply

Prosthodontics, other $0-525 copay Limits apply
oral/maxillofacial surgery,
& other services