Page 58 - APPENDICES for Diane Falten
P. 58
AMBULANCE
Ground ambulance In-network: $290 copay
Out-of-network: $290 copay
THERAPY SERVICES
Occupational therapy visit In-network: $40 copay Limits apply
Out-of-network: 30%
coinsurance
Physical therapy & speech In-network: $40 copay Limits apply
& language therapy visit Out-of-network: 30%
coinsurance
MENTAL HEALTH SERVICES
Outpatient group therapy In-network: $40 copay Limits apply
with a psychiatrist Out-of-network: 30%
coinsurance
Outpatient individual In-network: $40 copay Limits apply
therapy with a psychiatrist Out-of-network: 30%
coinsurance
Outpatient group therapy In-network: $40 copay Limits apply
visit Out-of-network: 30%
coinsurance
Outpatient individual In-network: $40 copay Limits apply
therapy visit Out-of-network: 30%
coinsurance
