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 />
30103 $233.10 30250 $1,586.20 30373 $615.65 30438 $1,466.20<br />
30104 $160.90 30251 $2,436.45 30375 $664.05 30439 $236.45<br />
30106 $197.00 30253 $1,057.45 30376 $664.05 30440 $670.60<br />
30107 $278.80 30255 $1,408.20 30378 $667.15 30441 $173.60<br />
30110 $360.55 30256 $564.70 30379 $1,182.45 30442 $236.45<br />
30111 $470.95 30259 $251.70 30382 $1,665.00 30443 $941.85<br />
30114 $470.95 30262 $74.50 30384 $1,400.65 30445 $941.85<br />
30165 $576.65 30265 $149.00 30385 $717.60 30446 $941.85<br />
30168 $576.65 30266 $189.80 30387 $809.00 30448 $1,239.50<br />
30171 $877.05 30269 $189.80 30388 $2,035.25 30449 $1,378.30<br />
30174 $877.05 30272 $374.90 30390 $280.15 30450 $668.05<br />
30177 $1,249.70 30275 $2,234.95 30391 $362.25 30451 $340.95<br />
30180 $173.00 30278 $58.95 30392 $859.25 30452 $480.90<br />
30183 $312.50 30281 $151.45 30393 $667.15 30454 $1,098.80<br />
30185 $231.40 30282 $197.00 30394 $627.85 30455 $1,291.90<br />
30186 $60.15 30283 $259.50 30396 $1,295.10 30457 $1,757.50<br />
30187 $325.75 30286 $504.45 30397 $296.00 30458 $1,291.90<br />
30189 $186.70 30289 $636.80 30399 $407.15 30460 $1,098.80<br />
30190 $504.30 30293 $564.70 30400 $805.80 30461 $1,883.50<br />
30192 $50.10 30294 $2,234.95 30402 $591.90 30463 $2,312.55<br />
30195 $80.50 30296 $1,297.90 30403 $664.05 30464 $2,775.15<br />
30196 $160.10 30297 $1,297.90 30405 $1,165.65 30466 $1,600.25<br />
30197 $557.95 30299 $808.20 30406 $66.50 30467 $1,979.45<br />
30202 $61.25 30300 $969.80 30408 $499.50 30469 $2,192.45<br />
30203 $215.85 30302 $646.55 30409 $222.25 30472 $1,183.95<br />
30205 $160.10 30303 $775.75 30411 $113.15 30473 $198.95<br />
30207 $56.50 30306 $1,012.55 30412 $66.65 30475 $359.80<br />
30210 $206.55 30308 $1,012.55 30414 $878.85 30476 $275.85<br />
30213 $139.20 30309 $1,297.90 30415 $1,757.50 30478 $275.85<br />
30214 $139.20 30310 $579.85 30416 $954.20 30479 $534.85<br />
30216 $34.65 30313 $346.05 30417 $1,431.20 30481 $401.10<br />
30219 $34.65 30314 $579.85 30418 $2,035.25 30482 $285.15<br />
30223 $206.55 30315 $1,445.20 30419 $1,041.00 30483 $198.90<br />
30224 $301.20 30317 $1,730.50 30421 $2,543.60 30484 $409.95<br />
30225 $339.30 30318 $1,150.75 30422 $860.35 30485 $632.85<br />
30226 $189.80 30320 $1,730.50 30425 $1,665.00 30487 $203.20<br />
30229 $346.05 30321 $1,150.75 30427 $1,988.65 30488 $101.05<br />
30232 $283.50 30323 $1,730.50 30428 $2,127.55 30490 $591.40<br />
30235 $374.90 30324 $1,730.50 30430 $2,959.90 30491 $623.90<br />
30238 $189.80 30329 $313.10 30431 $664.05 30492 $884.50<br />
30241 $451.80 30330 $911.25 30433 $925.00 30493 $374.35<br />
30244 $451.80 30332 $372.30 30434 $749.35 30494 $472.40<br />
30246 $874.60 30335 $1,106.40 30436 $832.50 30495 $884.50<br />
30247 $937.35 30336 $1,327.75 30437 $1,036.15 30496 $747.95<br />
30103 to 30496<br />
| MediGap 2010<br />
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