Page 63 - APPENDICES for Fred Falten

Out-of-network: Not Applicable
Limits apply

PREVENTIVE SERVICES

Preventive services
In-network: $0 copay

AMBULANCE

Ground ambulance
In-network: $295 copay

Out-of-network: $295 copay

THERAPY SERVICES

Occupational therapy visit

In-network: $40 copay
Out-of-network: $55 copay

Limits apply

Physical therapy & speech & language therapy visit

In-network: $40 copay
Out-of-network: $55 copay

Limits apply

MENTAL HEALTH SERVICES

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

Limits apply