SCHEDULE OF BENEFITS - nib
SCHEDULE OF BENEFITS - nib
SCHEDULE OF BENEFITS - nib
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Item No Benefit Item No Benefit Item No Benefit Item No Benefit<br />
31426 $1,021.70 32005 $1,586.80 32108 $1,220.60 32218 $197.80<br />
31429 $1,592.25 32006 $1,404.60 32111 $775.00 32220 $1,143.95<br />
31432 $1,703.00 32009 $1,666.25 32112 $943.00 32221 $1,143.95<br />
31435 $1,251.70 32012 $1,840.65 32114 $213.00 32500 $140.60<br />
31438 $1,984.00 32015 $2,262.00 32115 $154.90 32501 $140.60<br />
31441 $320.05 32018 $1,918.05 32117 $1,220.60 32504 $342.75<br />
31450 $517.10 32021 $687.80 32120 $313.70 32507 $683.35<br />
31452 $904.80 32024 $1,666.25 32123 $406.85 32508 $683.35<br />
31454 $716.30 32025 $2,228.80 32126 $590.95 32511 $1,015.95<br />
31456 $312.25 32026 $2,400.20 32129 $775.00 32514 $1,186.85<br />
31458 $374.70 32028 $2,571.80 32131 $651.55 32517 $1,528.35<br />
31460 $454.00 32029 $514.30 32132 $55.05 32700 $1,839.35<br />
31462 $662.85 32030 $1,259.30 32135 $82.40 32703 $1,521.70<br />
31464 $1,108.00 32033 $1,840.65 32138 $449.00 32708 $1,820.25<br />
31466 $1,662.05 32036 $2,334.40 32139 $449.00 32710 $2,022.55<br />
31468 $1,825.95 32039 $1,874.40 32142 $82.40 32711 $2,224.80<br />
31470 $915.85 32042 $1,579.00 32145 $164.90 32712 $1,608.30<br />
31472 $1,487.65 32045 $590.95 32147 $55.05 32715 $1,608.30<br />
31500 $330.70 32046 $913.20 32150 $313.70 32718 $1,521.70<br />
31503 $441.00 32047 $1,063.90 32153 $85.60 32721 $2,417.05<br />
31506 $496.10 32051 $2,828.65 32156 $160.85 32724 $2,744.60<br />
31509 $441.00 32054 $2,596.20 32159 $406.85 32730 $2,080.15<br />
31512 $826.80 32057 $687.80 32162 $590.95 32733 $2,417.05<br />
31515 $554.60 32060 $2,828.65 32165 $775.00 32736 $529.60<br />
31518 $936.30 32063 $2,596.20 32166 $251.80 32739 $1,656.40<br />
31521 $551.20 32066 $687.80 32168 $160.85 32742 $1,897.35<br />
31524 $1,322.85 32069 $2,092.50 32171 $108.40 32745 $2,166.80<br />
31527 $661.50 32072 $58.40 32174 $108.40 32748 $2,349.80<br />
31530 $757.50 32075 $91.60 32175 $198.55 32751 $1,521.70<br />
31533 $175.35 32078 $205.75 32177 $212.75 32754 $1,897.35<br />
31536 $240.80 32081 $282.60 32180 $313.70 32757 $529.60<br />
31539 $507.15 32084 $135.90 32183 $685.85 32760 $520.05<br />
31542 $250.45 32087 $249.95 32186 $685.85 32763 $1,521.70<br />
31545 $757.50 32090 $408.20 32200 $361.05 32766 $1,011.30<br />
31548 $175.35 32093 $572.85 32203 $775.35 32769 $350.45<br />
31551 $275.65 32094 $673.85 32206 $700.50 33050 $1,863.75<br />
31554 $551.20 32095 $156.00 32209 $1,125.70 33055 $1,494.60<br />
31557 $441.00 32096 $313.70 32210 $311.95 33070 $1,078.30<br />
31560 $441.00 32099 $406.85 32212 $166.35 33075 $1,371.70<br />
31563 $330.30 32102 $775.00 32213 $836.55 33080 $1,674.40<br />
31566 $165.25 32103 $943.00 32214 $422.65 33100 $1,839.35<br />
32000 $1,259.30 32104 $1,220.60 32215 $158.70 33103 $2,580.85<br />
32003 $1,317.30 32105 $590.95 32216 $751.25 33109 $3,120.30<br />
32004 $1,404.60 32106 $1,666.25 32217 $197.80 33112 $2,706.20<br />
31426 to 33112<br />
| MediGap 2010<br />
17