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Pagina 14
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 .550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 .550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
Pagina 16
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
Pagina 14
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 .550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
... including Ambulatory Surgical Center Expense , up to * ( Including Ambulance service up to $ 25 ) 200 700 1.000 SURGICAL BENEFITS Per Schedule up to 300 150 .550 Obstetrics ( Not Covered ) 112.50 137.50 DOCTOR'S VISITS IN - HOSPITAL ...
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