Network Available Per Plan Out of Network Out of Network Out of Network Out of Network InNetwork OutOfNetwork InNetwork OutOfNetwork InNetwork OutOfNetwork CC Non-CC Out of Network CC Non-CC Out of Network CC Non-CC Out of Network CC Non-CC Out of Network Deductible Per Person None NA $800 NA $1,600 NA $400 $500 $800 $800 $900 $1,600 $1,200 $1,300 $2,400 $1,600 $1,700 $3,200 Max Deduct Per Family None NA $2,400 NA $3,200 NA $1,500 $1,500 $2,400 $2,700 $2,700 $4,800 $3,900 $3,900 $7,200 $3,400 $3,400 $6,400 Max Out of Pocket Per Person $1,500 NA $4,000 NA $6,550 NA $2,850 $3,250 $6,000 $3,850 $4,250 $8,000 $4,850 $5,250 $10,000 $6,400 $6,750 $13,100 Max Out of Pocket Per Family $3,000 NA $12,000 NA $13,100 NA $9,750 $9,750 $18,000 $12,750 $12,750 $24,000 $15,750 $ 15,750 $ 27,400 $ 13,500 $ 13,500 $ 26,200常规考试 /健康$ 0不覆盖$ 0不覆盖$ 0不覆盖$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0在ded之后未覆盖$ 0。未覆盖$ 0 $ 0未覆盖$ 0 $ 0未覆盖$ 0 $ 0 $ 0未覆盖$ 0。$ 0之后。Not Covered Specialist Office Visit $30 Not Covered $35 Not Covered 20% Not Covered $40 20% 50% $40 20% 50% $50 25% 50% 15% 20% Not Covered Mental Health office visits $20 per Not Covered $25 per Not Covered 20% Not Covered $20 $20 50% $20 $20 50% $25 $25 50% 15% 20% 50% Labs, x-ray, and imaging $20 per Not Covered $25 per Not Covered 20% Not Covered 20% 20% 50% 20% 20% 50% 25% 25% 50% 20% 25% 50% CT, MRI, PET scans $70 per Not Covered $75 per Not Covered 20% Not Covered $100 + 20% $100 + 20% $100 + 50% $100 + 20% $100 + 20% $100 + 50% $100 + 25% $100 + 25% $100 + 50% 20% 25% 50% Acupuncture and Chiropractic $20 per Not Covered $25 per Not Covered 20%未覆盖$ 20 20％20％$ 20 20％50％$ 25 25％20％20％20％25％50％自然疗法办公室访问$ 20无覆盖$ 25 $ 25无覆盖20％未覆盖$ 40 20％50％$ 40 20％20％20％50％50％50％25％50％15％20％20％50％50％50％50％50％