23 Benefits In - Network Out - of - Network - Chiropractic / Osteopathic / Manipulative Therapy 2 0% Coinsurance after Deductible 30% Coinsurance after Deductible - Physical Therapy + 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Speech Therapy + 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Occupational Therapy + 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Dialysis 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Radiation / Chemotherapy Respiratory Therapy 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Cardiac Rehabilitation 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Pulmonary Therapy 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Cognitive Rehabilitation Therapy + 10% Coinsurance after Deductible 30% 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 D isorder benefits, as required by law. Out - of - Network Providers may also bill you for any charges over the Plan’s Maximum Allowed Amount. • Prescription Drugs Administered in the Office (other than allergy serum) 10% Coinsurance after Deductible 30% Coinsurance after Deductible Orthotics See “ Durable Medical Equipment (DME), Medical Devices, and Supplies. ” Outpatient Facility Services • Facility Surgery Charge 10% Coinsurance after Deductible 30% Coinsurance after Deductible • 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