Page 36 - APPENDICES for Diane Falten
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THERAPY SERVICES




       Occupational therapy visit             In-network: $40 copay                  Limits apply
                                              Out-of-network: $55 copay





       Physical therapy & speech              In-network: $40 copay                  Limits apply
       & language therapy visit               Out-of-network: $55 copay




   MENTAL HEALTH SERVICES



       Outpatient group therapy               In-network: $25 copay                  Limits apply
       with a psychiatrist                    Out-of-network: $30 copay





       Outpatient individual                  In-network: $25 copay                  Limits apply
       therapy with a psychiatrist            Out-of-network: $30 copay




       Outpatient group therapy               In-network: $25 copay                  Limits apply

       visit                                  Out-of-network: $30 copay




       Outpatient individual                  In-network: $25 copay                  Limits apply
       therapy visit                          Out-of-network: $30 copay




   OPIOID TREATMENT PROGRAM SERVICES



       Opioid treatment program               In-network: $0 copay                   Limits apply

       services
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