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 />
21380 $89.60 21670 $119.50 21908 $179.25 22031 $149.35<br />
21382 $119.50 21680 $89.60 21910 $268.85 22036 $89.60<br />
21390 $89.60 21682 $119.50 21912 $149.35 22040 $59.75<br />
21392 $119.50 21685 $298.75 21914 $179.25 22045 $89.60<br />
21400 $119.50 21700 $89.60 21915 $149.35 22050 $59.75<br />
21402 $209.10 21710 $119.50 21916 $149.35 22051 $271.25<br />
21403 $298.75 21712 $149.35 21918 $149.35 22055 $358.50<br />
21404 $149.35 21714 $149.35 21922 $209.10 22060 $597.50<br />
21420 $89.60 21716 $149.35 21925 $119.50 22065 $149.35<br />
21430 $119.50 21730 $89.60 21926 $149.35 22070 $298.75<br />
21432 $149.35 21732 $119.50 21927 $149.35 22075 $448.10<br />
21440 $239.00 21740 $149.35 21930 $179.25 22900 $179.25<br />
21445 $298.75 21756 $179.25 21935 $149.35 22905 $179.25<br />
21460 $89.60 21760 $209.10 21936 $179.25 23010 $29.85<br />
21461 $119.50 21770 $239.00 21939 $89.60 23021 $59.75<br />
21462 $89.60 21772 $179.25 21941 $209.10 23022 $59.75<br />
21464 $119.50 21780 $119.50 21942 $298.75 23023 $59.75<br />
21472 $149.35 21785 $298.75 21943 $149.35 23031 $89.60<br />
21474 $149.35 21790 $448.10 21945 $149.35 23032 $89.60<br />
21480 $119.50 21800 $89.60 21949 $149.35 23033 $89.60<br />
21482 $149.35 21810 $119.50 21952 $298.75 23041 $119.50<br />
21484 $149.35 21820 $89.60 21955 $149.35 23042 $119.50<br />
21486 $209.10 21830 $119.50 21959 $149.35 23043 $119.50<br />
21490 $89.60 21832 $209.10 21962 $149.35 23051 $149.35<br />
21500 $239.00 21834 $119.50 21965 $149.35 23052 $149.35<br />
21502 $179.25 21840 $239.00 21969 $239.00 23053 $149.35<br />
21520 $119.50 21842 $179.25 21970 $448.10 23061 $179.25<br />
21522 $149.35 21850 $119.50 21973 $149.35 23062 $179.25<br />
21530 $448.10 21860 $89.60 21976 $149.35 23063 $179.25<br />
21532 $239.00 21865 $298.75 21980 $149.35 23071 $209.10<br />
21535 $298.75 21870 $448.10 21981 $119.50 23072 $209.10<br />
21600 $89.60 21872 $239.00 21990 $89.60 23073 $209.10<br />
21610 $149.35 21878 $89.60 21992 $119.50 23081 $239.00<br />
21620 $119.50 21879 $149.35 21997 $119.50 23082 $239.00<br />
21622 $149.35 21880 $209.10 22001 $89.60 23083 $239.00<br />
21630 $149.35 21881 $268.85 22002 $119.50 23091 $268.85<br />
21632 $179.25 21882 $328.60 22007 $119.50 23101 $298.75<br />
21634 $268.85 21883 $388.35 22008 $119.50 23111 $328.60<br />
21636 $448.10 21884 $448.10 22012 $89.60 23112 $358.50<br />
21638 $298.75 21885 $507.85 22014 $89.60 23113 $388.35<br />
21650 $239.00 21886 $567.60 22015 $179.25 23114 $418.25<br />
21652 $298.75 21887 $627.35 22018 $209.10 23115 $448.10<br />
21654 $239.00 21900 $89.60 22020 $119.50 23116 $478.00<br />
21656 $298.75 21906 $149.35 22025 $119.50 23117 $507.85<br />
21380 to 23117<br />
| MediGap 2010<br />
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