• Facility Surgery Lab 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Facility Surgery X- 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after ray Deductible Deductible Deductible • Ancillary Services 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Doctor Surgery 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Charges Deductible Deductible Deductible • Other Doctor 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Charges (including Deductible Deductible Deductible Anesthesiologist, Pathologist, Radiologist, Surgical Assistant) • Other Facility 20% Coinsurance after $250 Copayment per 50% Coinsurance after Charges (for Deductible visit then 40% Deductible procedure rooms) Coinsurance after Deductible • Mental Health / 20% Coinsurance after $250 Copayment per 50% Coinsurance after Substance Use Deductible visit then 40% Deductible Disorder Outpatient Coinsurance after Facility Services Deductible (Partial Hospitalization Program / Intensive Outpatient Program) • Mental Health / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Substance Use Deductible Deductible Deductible Disorder Outpatient Facility Provider Services (e.g., Doctor and other professional Providers in a Partial Hospitalization Program / Intensive Outpatient Program) • Shots / Injections 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after (other than allergy Deductible Deductible Deductible serum) • Allergy Shots / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Injections (including Deductible Deductible Deductible allergy serum) • Diagnostic Lab 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible 25