22 injection(s) is billed by itself. The PCP or SCP office visit Copayment/Coinsur ance will apply if an office visit is billed with an allergy injection. • Diagnostic Lab (other than reference labs) No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Diagnostic X - ray No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Oth er Diagnostic Tests (including H earing and EKG) No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Office Surgery (including anesthesia) See PCP / SCP Copayment See PCP / SCP Copayment 50% Coinsurance after Deductible • Therapy Services: - Chiropractic / Osteopathic / Manipulative Therapy $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Physical Therapy + $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Speech Therapy + $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Occupational Therapy + $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Dialysis No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy See PCP / SCP Copayment See PCP / SCP Copayment 50% Coinsurance after Deductible - Cardiac Rehabilitation $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Pulmonary Therapy $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible