23 Benefits In - Network Out - of - Network • 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 . • Prescription Drugs Administered in an Outpatient Facility ( other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible Physical Therapy See “Therapy Services.”