Page 79 - Appendices to Jane Miller's evaluation

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: $70 copay

Limits apply

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

Limits apply

Eyeglasses (frames & lenses)

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

Limits apply