Page 67 - APPENDICES for Stephen Spero
P. 67

$0 copay






      AMBULANCE



      Ground ambulance
      20% coinsurance







      THERAPY SERVICES



      Occupational therapy visit
      20% coinsurance

      Limits apply



      Physical therapy & speech & language therapy visit

      20% coinsurance

      Limits apply






      MENTAL HEALTH SERVICES



      Outpatient group therapy with a psychiatrist
      20% coinsurance

      Limits apply



      Outpatient individual therapy with a psychiatrist

      20% coinsurance
      Limits apply




      Outpatient group therapy visit
      20% coinsurance

      Limits apply



      Outpatient individual therapy visit
      20% coinsurance


      Limits apply
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