Page 64 - APPENDICES for Vic Bosiger
P. 64
TESTS, LABS, & IMAGING
Diagnostic tests & In-network: $0-85 copay Limits apply
procedures Out-of-network: $0 copay or
40% coinsurance
Lab services In-network: $0-50 copay Limits apply
Out-of-network: 40%
coinsurance
Diagnostic radiology In-network: $35-275 copay Limits apply
services (like MRI) Out-of-network: 40%
coinsurance
Outpatient x-rays In-network: $0-105 copay Limits apply
Out-of-network: 40%
coinsurance
Emergency care $90 copay per visit (always
covered)
Urgent care $0-35 copay or 40%
coinsurance per visit (always
covered)
