Dana’s Visit Dana's Cost Sam's Visit Sam's Cost Maria's Visit Maria's Cost In this In-network: In this In-network: In this In-network: example, $0 example, Sam $60 example, $550 Dana would would pay Maria would pay (includes (includes pay (includes copays/ Out-of-network: copays/ Out-of-network: copays/ Out-of-network: coinsurance $0 coinsurance $80 coinsurance $900 and and and deductible, if deductible, if deductible, if applicable): applicable): applicable): Summary of Exam covered 2 Summary of Covered 1 per Summary of Covered 1 per what is not per 12 months; X- what is not tooth per surface what is not tooth per 60 covered or ray covered 1 per covered or per 24 months covered or months subject to a 60 months; subject to a subject to a limitation: Cleaning covered limitation: limitation: 2 per 12 months;