26 Radiologist, Surgical Assistant), Nutritional Counseling, and Diabetes Education • Other Facility Charges (for procedure rooms) 20% Coinsurance after Deductible $250 Copayment per visit then 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services Outpatient Facility Charges 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Professional Charges – Partial Hospitalization Program / Intensive Outpatient Program and Psychotherapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Professional Charges – Nutritional Counseling and Habilitative / Rehabilitative Therapies 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) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic Lab 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic X-ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Other Diagnostic Tests: Hearing, EKG, EEG etc. 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Therapy: - Chiropractic / Osteopathic / Manipulative Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible