pay your share of the cost for the emergency care. 
Urgently needed services $15 copay at an urgent care center 
Urgently needed services are provided to treat anon-emergency, 
unforeseen medical illness, injury or condition that requires immediate 
medical attention. 
OUTPATIENT CARE AND SERVICES 
Diagnostic services, labs and 
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