Page 56 - APPENDICES for Diane Falten
P. 56
TESTS, LABS, & IMAGING
Diagnostic tests & In-network: $0-95 copay Limits apply
procedures Out-of-network: $0 copay or
30% coinsurance
Lab services In-network: $0-45 copay Limits apply
Out-of-network: 30%
coinsurance
Diagnostic radiology In-network: $0-350 copay Limits apply
services (like MRI) Out-of-network: 30%
coinsurance
Outpatient x-rays In-network: $0-100 copay Limits apply
Out-of-network: 30%
coinsurance
Emergency care $90 copay per visit (always
covered)
Urgent care $0-45 copay or 30%
coinsurance per visit (always
covered)
