21 Benefits In - Network Out - of - Network • Retail Health Clinic Visit 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Family Planning, Diabetes Education, and Nutritional Counseling (Medical) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Nutritional Counseling (Mental Health and Substance Use Disorder) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Allergy Testing 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 (other than reference labs) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Diagnostic X - ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests (including Hearing and EKG) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Office Surgery (including anesthesia) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Therapy Services: - 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 - Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Radiation / Chemotherapy Respiratory Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible