23 Benefits In - Network Out - of - Network Outpatient Facility Charges 20% Coinsurance after Deductible 40% Coinsurance after Deductible Professional Charges – Partial Hospitalization Program / Intensive Outpatient Program and Psychotherapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible Professional Charges – Nutritional Counseling and Habilitative / Rehabilitative Therapies 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Shots/Injections (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Allergy Shots/Injections (including allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Diagnostic Lab 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Diagnostic X - ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests: Hearing , EKG, EEG etc. 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Therapy: - Chiropractic / Osteopathic / Manipulative Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Physical Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Speech Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Occupational Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Cognitive Rehabilitation Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible See “Therapy Services” for details on Benefit Maximums . +If physical, occupational, speech, or cognitive rehabilitation therapy is provided for a Mental Health or Substance Use Disorder condition (based on the primary diagnosis on the claim form), benefits will be paid under the Mental Health and Substance Use Disorder benefits, as required by law.