Premium$0MOOP $5,900PCP$0Specialist$30Referrals RequiredNoInpatient Hospital$325 (days 1-5)Ambulatory Surgery Center$0 or $245Outpatient Hospital$0 or $295Lab

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Premium$0MOOP $5,900PCP$0Specialist$35Referrals RequiredNoInpatient Hospital$295 (days 1-5)Ambulatory Surgery Center$0 or $200Outpatient Hospital$0 or $250Lab

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Premium$38MOOP $4,900PCP$0Specialist$35Referrals RequiredNoInpatient Hospital$250 (days 1-5)Ambulatory Surgery Center$0 or $175Outpatient Hospital$0 or $225Lab

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Premium $0 MOOP  $5,900 PCP $0 Specialist $40 Referrals Required No Inpatient

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Premium$0MOOP $5,900PCP$0Specialist$45Referrals RequiredNoInpatient Hospital$295 (days 1-5)Ambulatory Surgery Center$0 or $200Outpatient Hospital$0 or $250Lab

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