20 Benefits In-Network Out-of-Network • Retail Health Clinic Visit 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Counseling- includes Family Planning and Nutritional Counseling (Other than Eating Disorders) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Nutritional Counseling for Eating Disorders 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) 0% Coinsurance after Deductible 50% 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 - Pulmonary Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible