24 Facility Surgery Lab 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Facility Surgery X - ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Ancillary Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Doctor Surgery Charges 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Other Doctor Charges (including Anesthesiologist, Pathologist, Radiologist, Surgical Assistant) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible 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 Outpatient Facility Services (Partial Hospitalization Program / Intensive Outpatient Program) 20% Coinsurance after Deductible $250 Copayment per visit then 40% Coinsurance after Deductible 50% 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 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