imaging 
Cost share may vary depending 
on the service and where service 
is provided •Diagnostic mammography:  $25 to  $80 copay 
•Diagnostic radiology:  $100 to  $150 copay 
•Lab services:  $0 to  $50 copay 
•Diagnostic tests and procedures:  $0 to  $150 copay 
•Outpatient X-rays:  $0 to  $110 copay 
•Radiation therapy:  $25 copay or  20% of the cost  Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other