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In -Network <br />Diagnostic Diagnostic Procedures and Tests <br />Services/ <br />■ $30 copay at an Independent <br />Labs/Imaging 0 <br />Diagnostic Testing Facility (IDTF) <br />(Authorization <br />■ $100 copay at an outpatient <br />applies to in- <br />hospital facility <br />network <br />■ $0 copay for allergy testing <br />services only.) <br />Laboratory Services <br />■ $0 copay at an Independent <br />Clinical Laboratory <br />■ $30 copay at an outpatient <br />hospital facility <br />X -Rays <br />■ $50 copay at a physician's office <br />or at an IDTF <br />■ $150 copay at an outpatient <br />hospital facility <br />Advanced Imaging Services <br />Includes services such as Magnetic <br />Resonance Imaging (MRI), Positron <br />Emission Tomography (PET), and <br />Computer Tomography (CT) Scan <br />■ $75 copay at a physician's office <br />■ $100 copay at an IDTF <br />■ $150 copay at an outpatient <br />hospital facility <br />Radiation Therapy <br />■ 20% of the Medicare -allowed <br />amount <br />Out -of -Network <br />■ 40% of the Medicare -allowed amount <br />after $2,000 out -of -network deductible <br />7 333 <br />