Common use of Surgery Services Clause in Contracts

Surgery Services. Inpatient - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible Outpatient - hospital, ambulatory or independent surgical center - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible In a doctor’s office - doctor services 0% 0% 50% - After Deductible Telemedicine Telemedicine services - When rendered by a designated provider. $5 $5 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $600 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $75 $75 50% - After Deductible Outpatient Hospital facility Sleep Studies $600 $600 50% - After Deductible Outpatient Non-Hospital facility including in a doctor’s office, urgent care center, or free-standing outpatient facility, or other non-hospital setting Sleep Studies $200 $600 50% - After Deductible Outpatient Non-Hospital facilities: including; in a doctor’s office, urgent care center, or certain designated free- standing outpatient facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $200 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $25 $75 50% - After Deductible 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 0% - After Deductible 50% - After Deductible Lyme disease-diagnosis 0% - After Deductible 0% - After Deductible 50% - After Deductible

Surgery Services. Inpatient - doctor services 020% - After Deductible 020% - After Deductible 5060% - After Deductible Outpatient - hospitalOutpatient- hospital , ambulatory or independent surgical center - doctor services 020% - After Deductible 020% - After Deductible 5060% - After Deductible In a doctor’s office - doctor services 0% 0% 5060% - After Deductible Telemedicine Telemedicine services - When rendered by a designated provider. $5 10 $5 10 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $600 $600 5060% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 $150 5060% - After Deductible Lab and pathology services. Copayment is per provider per day. $75 $75 5060% - After Deductible Outpatient Hospital facility Sleep Studies $600 $600 50% - After Deductible Outpatient Non-Hospital facility including in a doctor’s office, urgent care center, or free-standing outpatient facility, or other non-hospital setting Sleep Studies $200 $600 5060% - After Deductible Outpatient Non-Hospital facilities: including; in a doctor’s office, urgent care center, or certain designated free- standing outpatient facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $200 $600 5060% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 $150 5060% - After Deductible Lab and pathology services. Copayment is per provider per day. $25 $75 5060% - After Deductible Outpatient Non-Hospital facility Sleep Studies $200 $600 60% - After Deductible 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 020% - After Deductible 5060% - After Deductible Lyme disease-diagnosis 020% - After Deductible 020% - After Deductible 5060% - After Deductible

Surgery Services. Inpatient - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible Outpatient - hospitalOutpatient- hospital , ambulatory or independent surgical center - doctor services 0% - After Deductible 0% - After Deductible 50% - After Deductible In a doctor’s office - doctor services 0% 0% 50% - After Deductible Telemedicine Telemedicine services - When rendered by a designated provider. $5 10 $5 10 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $600 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $75 $75 50% - After Deductible Outpatient Hospital facility Sleep Studies $600 $600 50% - After Deductible Outpatient Non-Hospital facility including in a doctor’s office, urgent care center, or free-standing outpatient facility, or other non-hospital setting Sleep Studies $200 $600 50% - After Deductible Outpatient Non-Hospital facilities: including; in a doctor’s office, urgent care center, or certain designated free- standing outpatient facilities MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* Copayment is applied per service. $200 $600 50% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 $150 50% - After Deductible Lab and pathology services. Copayment is per provider per day. $25 $75 50% - After Deductible Outpatient Non-Hospital facility Sleep Studies $200 $600 50% - After Deductible 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 0% - After Deductible 50% - After Deductible Lyme disease-diagnosis 0% - After Deductible 0% - After Deductible 50% - After Deductible