Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $10 - $65 copay/visit $195 copay/visit Certain procedures performed in the office may have a higher office visit copay. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. *Cost share applies to any other Telehealth service based on provider type. If you receive services in addition to office visit, additional copays may apply. Specialist visit $10 - $65 copay/visit $195 copay/visit Preventive care/screening/ immunization No charge $100 copay/visit You may have to pay for services that are not preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Routine diagnostic test (e.g., x-ray, blood work) Non-routine diagnostic test (e.g., sleep study, genetic testing) Routine diagnostic test: No charge Non-routine diagnostic test: $10 - $800 copay/visit Routine diagnostic test: No charge Non-routine diagnostic test: Up to $2,400 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for certain Non-routine diagnostic tests or there may be no coverage. Imaging (CT/PET scans, MRIs) $75 - $950 copay/visit Up to $2,850 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for certain imaging tests or there may be no coverage. *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.