•Lab services:  $0 to  $20 copay 
•Diagnostic tests and procedures:  $0 to  $105 copay 
•Outpatient X-rays:  $0 to  $75 copay 
•Radiation therapy:  $15 copay or  20% of the cost  
Hearing Medicare-covered hearing exam:  $15 copay  
Routine hearing:  
In-Network: 
HER939 
•$0 copay for routine hearing exams up to 1per year. 
•$499 copay for each Advanced level hearing aid up to 1per ear per  
year. 
•$799 copay for each Premium level hearing aid up to 1per ear per  
year. 
Hearing aid purchase includes: