24 Substance Use Disorder) • Allergy Testing 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Shots / Injections (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Allergy Shots / Injections (including allergy serum) A $10 Copayment for allergy injection(s) will be applied when the injection(s) is billed by itself. The PCP or SCP office visit Copayment/Coinsuran ce will apply if an office visit is billed with an allergy injection. 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • 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 • Other Diagnostic Tests (including Hearing 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