Page 77 - APPENDICES for Fred Falten
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ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,678.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$8,500 In and Out-of-network
$6,700 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
In-network: $0 copay
Out-of-network: $20 copay per visit
Specialist visit
In-network: $45 copay per visit
Out-of-network: $65 copay per visit
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
In-network: $0-95 copay
Out-of-network: $0-65 copay or 30% coinsurance
Limits apply
Lab services
In-network: $0-45 copay
Out-of-network: $20-65 copay or 30% coinsurance
