26 Benefits In - Network Out - of - Network Prosthetics See “ Durable Medical Equipment (DME), Medical Devices, and Supplies. ” Pulmonary Therapy See “Therapy Services.” Radiation Therapy See “Therapy Services.” Rehabilitation Services Benefits are based on the setting in which Covered Services are received. See “Inpatient Services” and “Therapy Services” for details on Benefit Maximums. Respiratory Therapy See “Therapy Services.” Skilled Nursing Facility See “Inpatient Services.” Speech Therapy See “Therapy Services.” Surgery Benefits are based on the setting in which Covered Services are received. • Inpatient Bariatric Surgery $150 Copayment per surgery then 10% Coinsurance 30% Coinsurance • Outpatient Bariatric Surgery $50 Copayment per surgery then 10% Coinsurance 30% Coinsurance • Bariatric Surgery Lifetime Maximum One (1) surgery per Lifetime Temporomandibular and Craniomandibular Joint Treatment Benefits are based on the setting in which Covered Services are received. Therapy Services Benefits are based on the setting in which Covered Services are received. Benefit Maximum(s): Benefit Maximum(s) are for In - and Out - of - Network visits combined, and for office and outpatient visits combined. • Physical Therapy Unlimited