Common use of Surgery Services Clause in Contracts

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible Telemedicine services When rendered by a designated provider. $20 Not Covered Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible Lab and pathology services. 0% 20% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 20% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After Deductible

Surgery Services. Inpatient doctor services 020% - After Deductible 2040% - After Deductible Outpatient doctor services 020% - After Deductible 2040% - After Deductible In a doctor’s office 0% 2040% - After Deductible Telemedicine services When rendered by a designated provider. $20 Not Covered Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 020% - After Deductible 2040% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 2040% - After Deductible Lab and pathology services. 0% 2040% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After Deductible 2040% - After Deductible Lyme disease-diagnosis 020% - After Deductible 2040% - After Deductible

Surgery Services. Inpatient doctor services 0% - After Deductible 200% - After Deductible Outpatient doctor services 0% - After Deductible 200% - After Deductible In a doctor’s office 0% 20- After Deductible 0% - After Deductible Telemedicine services When rendered by a designated provider. $20 0% - After Deductible Not Covered Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 200% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20- After Deductible 0% - After Deductible Lab and pathology services. 0% 20- After Deductible 0% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 200% - After Deductible Lyme disease-diagnosis 0% - After Deductible 200% - After Deductible

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible Telemedicine services When rendered by a designated provider. $20 25 Not Covered Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible Lab and pathology services. 0% 20% - After Deductible See Section 3.0 – Covered Health Care Services for additional benefit limits and coverage information. Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 20% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After Deductible