22 icine Services from a Specialty Care Provider (SCP) (as required by law) Retail Health Clinic Visit $15 Copayment per visit $40 Copayment per visit 50% Coinsurance after Deductible Counseling - includes Family Planning and Nutritional Counseling (Other than Eating Disorders) $15 Copayment per visit $40 Copayment per visit 50% Coinsurance after Deductible Nutritional Counseling for Eating Disorders $15 Copayment per visit $40 Copayment per visit 50% Coinsurance after Deductible 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/Coinsur ance 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 Oth er Diagnostic Tests (including H earing and EKG) No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible