24 Benefits In - Network Out - of - Network Orthotics See “ Durable Medical Equipment (DME), Medical Devices, and Supplies. ” Outpatient Facility Services • Facility Surgery Charge $50 Copayment per visit then 10% Coinsurance 30% Coinsurance • Facility Surgery Lab 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Facility Surgery X - ray 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Ancillary Services 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Doctor Surgery Charges $40 Copayment per visit then 10% Coinsurance 30% Coinsurance • Other Doctor Charges (including Anesthesiologist, Pathologist, Radiologist, Surgical Assistant), Nutritional Counseling, and Diabetes Education $40 Copayment per visit then 10% Coinsurance 30% Coinsurance • Other Facility Charges (for procedure rooms) $ 5 0 Copayment per visit then 10% Coinsurance 30% Coinsurance • Mental Health / Substance Use Disorder Services Outpatient Facility Charges 10% Coinsurance after Deductible 30% Coinsurance after Deductible Professional Charges – Partial Hospitalization Program / Intensive Outpatient Program and Psychotherapy $ 45 Copayment per visit 30% Coinsurance after Deductible Professional Charges – Nutritional Counseling and Habilitative / Rehabilitative Therapies $ 45 Copayment per visit 30% Coinsurance after Deductible • Shots/Injections (other than allergy serum) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Allergy Shots/Injections (including allergy serum) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Diagnostic Lab 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Diagnostic X - ray 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Other Diagnostic Tests: Hearing EKG, EEG etc. 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 10% Coinsurance after Deductible 30% Coinsurance after Deductible