Page 63 - APPENDICES for Janet Tuma

AMBULANCE

Ground ambulance
$200 copay

THERAPY SERVICES

Occupational therapy visit
$20 copay

Limits apply

Physical therapy & speech & language therapy visit
$20 copay

Limits apply

MENTAL HEALTH SERVICES

Outpatient group therapy with a psychiatrist
$25 copay

Limits apply

Outpatient individual therapy with a psychiatrist
$25 copay

Limits apply

Outpatient group therapy visit
$25 copay

Limits apply

Outpatient individual therapy visit

$25 copay
Limits apply