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X -Rays <br />■ $50 copay at a physician's office or <br />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), Magnetic <br />Resonance Angiography (MRA), <br />Positron Emission Tomography (PET), <br />Computer Tomography (CT) scan or <br />Nuclear Medicine testing. <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 />N <br />In-Network Out-of-Network <br />• $25,000 combined yearly limit for Worldwide Emergency Care and <br />Worldwide Urgently Needed Services <br />Does not include emergency transportation. <br />Diagnostic <br />Diagnostic Procedures and Tests 40% of the Medicare-allowed <br />Services/ <br />■ $30 copay at an Independent amount after $2,000 <br />Labs/Imaging 0 <br />Diagnostic Testing Facility (IDTF) out-of-network deductible <br />(Authorization <br />■ $100 copay at an outpatient <br />applies to <br />hospital facility <br />in-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 or <br />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), Magnetic <br />Resonance Angiography (MRA), <br />Positron Emission Tomography (PET), <br />Computer Tomography (CT) scan or <br />Nuclear Medicine testing. <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 />N <br />