21 Benefits In-Network Out-of-Network Out-of-Network Providers may also bill you for any charges over the Plan’s Maximum Allowed Amount. See “Therapy Services” for details on Benefit Maximums. • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible Orthotics See “Durable Medical Equipment (DME), Medical Devices, and Supplies.” Outpatient Facility Services • Facility Surgery Charge 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Facility Surgery Lab 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Facility Surgery X-ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Doctor Surgery Charges 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Doctor Charges (including Anesthesiologist, Pathologist, Radiologist, Surgical Assistant) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Facility Charges (for procedure rooms) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Mental Health / Substance Use Disorder Outpatient Facility Services (Partial Hospitalization Program / Intensive Outpatient Program) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Mental Health / Substance Use Disorder Outpatient Facility Provider Services (e.g., Doctor and other professional Providers in a Partial Hospitalization Program / Intensive Outpatient Program) 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 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Diagnostic X-ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests: Hearing EKG, EEG etc. 20% Coinsurance after Deductible 40% Coinsurance after Deductible