Page 65 - APPENDICES for Stephen Spero
P. 65
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$4,205.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$6,700 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
20% coinsurance per visit
Specialist visit
20% coinsurance per visit
Limits apply
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
20% coinsurance
Limits apply
Lab services
20% coinsurance
Limits apply
Diagnostic radiology services (like MRI)
20% coinsurance
