Page 52
Service/Item Co-payment Limitations/Cumulative Maximum $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00
WISCONSIN
Effective Date:
Approval Date: 52
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Service/Item Co-payment Limitations/Cumulative Maximum $25.01 to $50……….………...$2.00 $50.01 or more…….………….$3.00
WISCONSIN
Effective Date:
Approval Date: 52