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Other Services <br />Outpatient Surgery In -Network <br />• $250 Copayment for each outpatient hospital <br />facility visit <br />• $175 Copayment for each visit to an <br />ambulatory surgical center <br />Out -of -Network Deductible & 40% Coinsurance <br />Diagnostic Tests, X -Rays <br />Office <br />IDTF <br />Outpatient Hospital <br />In -Network <br />• PCP $35 Copayment <br />• Specialist $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $100 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $250 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Lab Services <br />Independent Clinical Lab <br />Outpatient Hospital <br />All Locations <br />In -Network $0 Copayment <br />In -Network $30 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Advanced Imaging (MRI, MRA, CT Scan, <br />PET Scan and Nuclear Medicine) <br />Office In -Network $175 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />IDTF <br />In -Network $175 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Outpatient Hospital In -Network $250 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Y0011 34432 M 0918 EGWP C: 09/2018 2 <br />