Page 47 - APPENDICES for Stephen Spero
P. 47
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$4,027.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$3,400 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
$10 copay per visit
Specialist visit
$35 copay per visit
Limits apply
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
$0 copay or 20% coinsurance
Limits apply
Lab services
$0-5 copay
Limits apply
Diagnostic radiology services (like MRI)
$120 copay
