25 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 - Physical Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Speech Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Occupational Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible See Therapy Services for details on Benefit Maximums. Prescription Drugs Administered in an Outpatient Facility (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Physical Therapy See Therapy Services. Preventive Care No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible