Page 34 - APPENDICES for Diane Falten
P. 34
TESTS, LABS, & IMAGING
Diagnostic tests & In-network: 0-15% Limits apply
procedures coinsurance
Out-of-network: 0-15%
coinsurance
Lab services In-network: $0-5 copay or 0- Limits apply
20% coinsurance
Out-of-network: $0-5 copay
or 0-20% coinsurance
Diagnostic radiology In-network: 20% coinsurance Limits apply
services (like MRI) Out-of-network: 30%
coinsurance
Outpatient x-rays In-network: 15% coinsurance Limits apply
Out-of-network: 15%
coinsurance
Emergency care $90 copay per visit (always
covered)
Urgent care $40 copay per visit (always
covered)
