Schedule of Benefits (continued) Preferred Blue PPO Deductible II This chart shows your cost share for covered services. You must pay all charges in excess of a benefit limit. Page 10 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  Office and health center surgical services Surgery as an Outpatient (continued) by another specialist or other covered provider (non-hospital), including a physician assistant or nurse practitioner designated by the health plan as specialty care $40 copayment per visit after deductible 20% after deductible  Outpatient x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests  Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient  Outpatient physical therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy TMJ Disorder Treatment  Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits