Basic Calculation Assignment (In-Network) Deductible: $1,250.00 Policy Information Name: Copayments: (Only the services listed below are copayments - All others services are coinsurance) In-Network Primary Care Physician Office Visit: $20.00 In-Network Specialist Physician Office Visit: $30.00 In-Network Emergency Department Visits: $250.00 In-Network Outpatient Therapy Visit: $20.00 Urgent Care Center Visit: $65.00 Coinsurance: 80/20 % (All other healthcare services are paid under coinsurance) Maximum Out-Of-Pocket (OOP): $4,000.00 Tara had a hysterectomy at Hawkins Surgery Center on January 21. The allowable for Hawkins Outpatient Surgery Center is $2934.00. How will the payment to the surgery center take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $75.00 Remaining Maximum OOP: $3,925.00 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $2934.00 Deductible (Patient) $ Coinsurance/Copayment (Patient) $ Insurance Payment $ is $ $