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 />
53410 $109.40 55079 $46.60 55736 $159.10 59974 $104.20<br />
53411 $305.05 55084 $121.05 55739 $71.40 60000 $686.65<br />
53412 $500.95 55085 $41.95 55759 $187.90 60003 $1,007.00<br />
53413 $613.65 55113 $296.55 55762 $75.15 60006 $1,431.90<br />
53414 $705.05 55114 $296.55 55764 $200.40 60009 $1,675.65<br />
53415 $556.55 55115 $296.55 55766 $81.40 60012 $686.65<br />
53416 $556.55 55116 $329.25 55768 $187.90 60015 $1,007.00<br />
53418 $723.55 55117 $329.25 55770 $75.15 60018 $1,431.90<br />
53419 $723.55 55118 $306.85 55772 $200.40 60021 $1,675.65<br />
53422 $918.25 55130 $213.90 55774 $81.40 60024 $686.65<br />
53423 $918.25 55135 $445.00 58500 $43.70 60027 $1,007.00<br />
53424 $787.85 55238 $226.65 58503 $58.30 60030 $1,431.90<br />
53425 $787.85 55244 $226.65 58506 $75.15 60033 $1,675.65<br />
53427 $1,076.05 55246 $226.65 58509 $49.15 60036 $686.65<br />
53429 $1,076.05 55248 $226.65 58521 $53.65 60039 $1,007.00<br />
53439 $305.05 55252 $226.65 58524 $69.90 60042 $1,431.90<br />
53453 $617.40 55274 $226.65 58527 $85.85 60045 $1,675.65<br />
53455 $725.20 55276 $226.65 59300 $110.75 60048 $686.65<br />
53458 $54.95 55278 $226.65 59303 $66.75 60051 $1,007.00<br />
53459 $300.80 55280 $226.65 59306 $124.10 60054 $1,431.90<br />
53460 $613.65 55282 $226.65 59309 $248.20 60057 $1,675.65<br />
53600 $49.70 55284 $226.65 59312 $107.65 60060 $686.65<br />
53700 $159.45 55292 $226.65 59314 $64.95 60063 $1,007.00<br />
53702 $79.85 55294 $226.65 59318 $58.20 60066 $1,431.90<br />
53704 $48.10 55296 $136.85 59700 $119.45 60069 $1,675.65<br />
53706 $159.45 55600 $134.15 59703 $93.90 60072 $58.55<br />
55028 $134.40 55603 $134.15 59712 $140.70 60075 $117.00<br />
55029 $46.60 55700 $75.15 59715 $177.65 60078 $175.60<br />
55030 $134.40 55703 $43.80 59718 $166.60 60500 $53.65<br />
55031 $46.60 55704 $87.65 59724 $280.20 60503 $36.80<br />
55032 $134.40 55705 $43.80 59733 $133.25 60506 $78.85<br />
55033 $46.60 55706 $125.25 59736 $76.70 60509 $122.35<br />
55036 $137.10 55707 $87.65 59739 $91.25 61109 $320.55<br />
55037 $46.60 55708 $43.80 59751 $172.20 61302 $488.55<br />
55038 $134.40 55709 $47.60 59754 $271.45 61303 $615.30<br />
55039 $46.60 55712 $144.05 59760 $142.50 61306 $772.50<br />
55044 $137.10 55715 $50.10 59763 $165.70 61307 $908.75<br />
55045 $46.60 55718 $125.25 59903 $143.55 61310 $399.80<br />
55048 $134.90 55721 $144.05 59912 $382.55 61313 $330.15<br />
55049 $46.60 55723 $47.60 59925 $454.35 61314 $457.15<br />
55054 $134.40 55725 $50.10 59970 $208.35 61316 $414.85<br />
55070 $121.05 55729 $34.10 59971 $71.80 61317 $535.95<br />
55073 $41.95 55731 $122.75 59972 $191.25 61320 $249.15<br />
55076 $134.40 55733 $43.80 59973 $227.15 61328 $247.75<br />
53410 to 61328<br />
| MediGap 2010<br />
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