24 Benefits In - Network Out - of - Network • Doctor Surgery Charges 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Other Doctor Charges (including Anesthesiologist, Pathologist, Radiologist, Surgical Assistant), Nutritional Counseling, and Diabetes Education 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Other Facility Charges (for procedure rooms) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services Outpatient Facility Charges 10% Coinsurance after Deductible 4 0% Coinsurance after Deductible Professional Charges – Partial Hospitalization Program / Intensive Outpatient Program and Psychotherapy 10% Coinsurance after Deductible 30% Coinsurance after Deductible Professional Charges – Nutritional Counseling and Habilitative / Rehabilitative Therapies 10% Coinsurance after Deductible 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 40% Coinsurance after Deductible • Diagnostic X - ray 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests: Hearing EKG, EEG etc. 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Therapy: - Chiropractic / Osteopathic / Manipulative Therapy 20% 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 - Radiation / Chemotherapy / Respiratory Therapy 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Dialysis 10% Coinsurance after Deductible 30% Coinsurance after Deductible - Cardiac Rehabilitation 10% Coinsurance after Deductible 30% Coinsurance after Deductible