SCHEDULE OF BENEFITS - nib
SCHEDULE OF BENEFITS - nib
SCHEDULE OF BENEFITS - nib
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Item No Benefit Item No Benefit Item No Benefit Item No Benefit<br />
15315 $782.70 15700 $57.25 16633 DERIVED 18278 $129.05<br />
15316 $782.70 15705 $95.45 16636 DERIVED 18280 $181.70<br />
15319 $485.80 15710 $95.45 17610 $62.55 18282 $146.70<br />
15320 $485.80 15800 $120.10 17615 $124.55 18284 $214.95<br />
15323 $863.80 15850 $248.75 17620 $172.55 18286 $214.95<br />
15324 $863.80 16003 $699.60 17625 $219.75 18288 $214.95<br />
15327 $939.70 16006 $537.60 17640 $62.55 18290 $363.60<br />
15328 $939.70 16009 $366.90 17645 $124.55 18292 $181.70<br />
15331 $892.25 16012 $317.40 17650 $172.55 18294 $256.15<br />
15332 $892.25 16015 $4,394.25 17655 $219.75 18296 $219.15<br />
15335 $809.75 16018 $2,626.85 17680 $124.55 18298 $256.15<br />
15336 $809.75 16401 $107.10 18213 $129.05 18350 $181.70<br />
15338 $1,119.35 16404 $53.80 18216 $276.45 18351 $181.70<br />
15339 $91.20 16500 $59.00 18219 DERIVED 18352 $363.55<br />
15342 $227.65 16501 $176.00 18222 $54.85 18354 $181.70<br />
15345 $607.55 16502 $59.00 18225 $72.85 18356 $181.70<br />
15348 $69.85 16504 $59.00 18226 $414.60 18358 $181.70<br />
15351 $139.50 16505 $59.00 18227 DERIVED 18360 $181.70<br />
15354 $169.30 16508 $59.00 18228 $91.00 18362 $359.05<br />
15357 $47.90 16509 $59.00 18230 $347.10 18364 $181.70<br />
15360 $431.85 16511 $275.40 18232 $276.45 18366 $227.65<br />
15363 $431.85 16512 $79.50 18233 $276.45 18368 $388.65<br />
15500 $278.90 16514 $45.85 18234 $181.70 18370 $65.55<br />
15503 $358.05 16515 $948.25 18236 $91.00 18371 $65.55<br />
15506 $534.70 16518 $490.50 18238 $54.85 18372 $181.70<br />
15509 $241.70 16519 $1,460.10 18240 $136.25 18373 $181.70<br />
15512 $311.55 16520 $1,706.55 18242 $54.85 20100 $149.40<br />
15513 $352.30 16522 $2,157.75 18244 $146.70 20102 $179.30<br />
15515 $451.10 16525 $808.70 18246 $146.70 20104 $119.50<br />
15518 $88.45 16564 $279.45 18248 $129.05 20120 $149.40<br />
15521 $390.60 16567 $408.65 18250 $91.00 20124 $119.50<br />
15524 $732.45 16570 $533.35 18252 $146.70 20140 $149.40<br />
15527 $90.75 16571 $408.65 18254 $146.70 20142 $179.30<br />
15530 $404.70 16573 $333.05 18256 $91.00 20143 $179.30<br />
15533 $767.35 16600 $81.30 18258 $91.00 20144 $239.05<br />
15536 $306.65 16603 $156.10 18260 $129.05 20145 $239.05<br />
15539 $720.95 16606 $311.55 18262 $91.00 20146 $149.40<br />
15541 $306.65 16609 $635.35 18264 $146.70 20147 $179.30<br />
15550 $756.90 16612 $499.85 18266 $91.00 20148 $119.50<br />
15553 $816.60 16615 $266.20 18268 $129.05 20160 $179.30<br />
15556 $763.50 16618 $266.20 18270 $129.05 20162 $209.20<br />
15559 $995.90 16621 $266.20 18272 $91.00 20164 $119.50<br />
15562 $1,288.00 16624 $383.10 18274 $129.05 20170 $179.30<br />
15600 $1,959.45 16627 $780.05 18276 $181.70 20172 $209.20<br />
15315 to 20172<br />
| MediGap 2010<br />
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