Premium$19MOOP $6,700PCP$0Specialist$40Referrals RequiredNoInpatient Hospital$335 (days 1-5)Ambulatory Surgery Center$0 or $335Outpatient Hospital$0 or $335Lab

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Premium$0 for Full DualsMOOP $0 for Full DualsPCP$0 for Full DualsSpecialist$0 for Full

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Premium $0 ; Part B Rebate: $30 MOOP  $6,700 PCP $0 Specialist

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Premium$24MOOP $4,500PCP$0Specialist$30Referrals RequiredNoInpatient Hospital$295 (days 1-6)Ambulatory Surgery Center$0 or $195Outpatient Hospital$0 or $295Lab

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Premium$0MOOP $5,900PCP$0Specialist$45Referrals RequiredNoInpatient Hospital$325 (days 1-6)Ambulatory Surgery Center$0 or $225Outpatient Hospital$0 or $325Lab

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