Page 68 - Appendices for Eric Hartman
P. 68
TESTS, LABS, & IMAGING
Diagnostic tests & In-network: $0 copay
procedures Out-of-network: 30%
coinsurance
Lab services In-network: $0 copay
Out-of-network: 30%
coinsurance
Diagnostic radiology In-network: $150 copay Limits apply
services (like MRI) Out-of-network: 30%
coinsurance
Outpatient x-rays In-network: $15 copay Limits apply
Out-of-network: 30%
coinsurance
Emergency care $85 copay per visit (always
covered)
Urgent care $20 copay per visit (always
covered)
