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 />
45468 $2,538.35 45536 $634.10 45617 $325.55 45714 $1,083.00<br />
45469 $1,915.10 45539 $1,483.70 45620 $451.60 45716 $1,083.00<br />
45471 $3,190.65 45542 $849.55 45623 $1,001.45 45720 $1,339.00<br />
45472 $2,406.65 45545 $862.20 45624 $1,298.30 45723 $1,510.10<br />
45474 $3,841.20 45546 $274.00 45625 $259.75 45726 $1,706.50<br />
45475 $2,898.20 45548 $383.35 45626 $451.60 45729 $1,916.45<br />
45477 $4,491.75 45551 $614.55 45629 $656.15 45731 $1,942.80<br />
45478 $3,387.95 45552 $884.55 45632 $709.05 45732 $2,187.25<br />
45480 $5,142.15 45553 $884.55 45635 $813.85 45735 $2,231.35<br />
45481 $3,879.65 45554 $968.75 45638 $1,404.50 45738 $2,510.30<br />
45483 $5,858.70 45555 $884.55 45639 $1,404.50 45741 $2,454.70<br />
45484 $4,420.40 45556 $1,060.95 45641 $1,499.80 45744 $2,760.00<br />
45485 $730.85 45557 $1,060.95 45644 $1,772.10 45747 $2,678.05<br />
45486 $624.75 45558 $1,591.40 45645 $309.70 45752 $2,999.65<br />
45487 $562.45 45559 $1,574.55 45646 $1,247.10 45753 $3,017.50<br />
45488 $624.75 45560 $656.00 45647 $1,772.10 45754 $3,617.20<br />
45489 $937.45 45561 $2,458.00 45650 $204.70 45755 $509.30<br />
45490 $1,250.00 45562 $1,522.70 45652 $493.55 45758 $911.45<br />
45491 $1,562.35 45563 $1,522.70 45653 $493.55 45761 $1,036.90<br />
45492 $1,874.75 45564 $3,526.70 45656 $695.65 45767 $3,478.70<br />
45493 $562.45 45565 $2,645.15 45659 $721.95 45770 $2,664.75<br />
45494 $2,269.65 45566 $1,483.70 45660 $3,987.15 45773 $2,428.50<br />
45496 $576.25 45568 $614.55 45661 $1,772.10 45776 $2,428.50<br />
45497 $450.05 45569 $938.45 45662 $971.25 45779 $1,785.50<br />
45498 $362.20 45570 $1,267.25 45665 $451.60 45782 $1,365.20<br />
45499 $270.05 45572 $404.00 45668 $451.60 45785 $2,310.40<br />
45500 $1,510.10 45575 $997.45 45669 $451.60 45788 $2,284.05<br />
45501 $2,458.00 45578 $1,155.20 45671 $1,155.20 45791 $1,233.85<br />
45502 $2,458.00 45581 $383.35 45674 $336.00 45794 $697.80<br />
45503 $2,812.15 45584 $874.95 45675 $669.30 45797 $258.25<br />
45504 $2,458.00 45585 $874.95 45676 $796.80 45799 $40.80<br />
45505 $2,458.00 45586 $874.95 45677 $749.80 45801 $175.75<br />
45506 $304.60 45587 $1,233.85 45680 $937.45 45803 $451.60<br />
45512 $409.55 45588 $1,851.00 45683 $1,041.40 45805 $238.95<br />
45515 $258.25 45590 $669.30 45686 $1,229.20 45807 $341.40<br />
45518 $312.60 45593 $786.20 45689 $362.45 45809 $514.50<br />
45519 $594.25 45596 $1,247.10 45692 $416.50 45811 $695.65<br />
45520 $1,247.10 45597 $1,669.50 45695 $676.95 45813 $813.85<br />
45522 $874.95 45599 $1,297.20 45698 $635.35 45815 $493.55<br />
45524 $1,027.20 45602 $968.75 45701 $1,145.85 45817 $643.35<br />
45527 $1,027.20 45605 $813.85 45704 $416.50 45819 $813.80<br />
45528 $1,540.65 45608 $1,145.85 45707 $1,083.00 45821 $527.35<br />
45530 $1,522.70 45611 $656.15 45710 $676.95 45823 $150.75<br />
45533 $1,724.55 45614 $813.85 45713 $770.90 45825 $468.65<br />
45468 to 45825<br />
| MediGap 2010<br />
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