Page 76 - APPENDICES for Diane Falten
P. 76
TESTS, LABS, & IMAGING
Diagnostic tests & In-network: 20% coinsurance Limits apply
procedures Out-of-network: 20%
coinsurance
Lab services In-network: $0-5 copay or 0- Limits apply
20% coinsurance
Out-of-network: 20%
coinsurance
Diagnostic radiology In-network: 20% coinsurance
services (like MRI) Out-of-network: 30%
coinsurance
Outpatient x-rays In-network: $12 copay
Out-of-network: 30%
coinsurance
Emergency care $90 copay per visit (always
covered)
Urgent care $45 copay per visit (always
covered)
