Name: Basic Calculation Assignment (In-Network) Policy Information Deductible: $2,500.00 Copayments: (Only the services listed below are copayments - All others services are coinsurance) In-Network Primary Care Physician Office Visit: $25.00 In-Network Specialist Physician Office Visit: $35.00 In-Network Emergency Department Visits: $500.00 In-Network Outpatient Therapy Visit: $50.00 Urgent Care Center Visit: $75.00 Outpatient Surgery Center $750.00 Coinsurance: 80/20% (All other healthcare services are paid under coinsurance) Maximum Out-Of-Pocket (OOP): $4,500.00 6. A patient had cataract surgery at See Clear Outpatient Surgery Center. The allowable for Hawkins Outpatient Surgery Center is $1987.56. How will the payment to the surgery center take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $385.00 Remaining Maximum OOP: $1,987.54 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ Insurance Payment $ $ $ 7. Joey went for his first speech therapy appointment. The allowable $165.32. How will the payment to the speech therapist take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $1,250.00 Remaining Maximum OOP: $455.35 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ Insurance Payment $ $ Name: Basic Calculation Assignment (In-Network) Policy Information Deductible: $2,500.00 Copayments: (Only the services listed below are copayments - All others services are coinsurance) In-Network Primary Care Physician Office Visit: $25.00 In-Network Specialist Physician Office Visit: $35.00 In-Network Emergency Department Visits: $500.00 In-Network Outpatient Therapy Visit: $50.00 Urgent Care Center Visit: $75.00 Outpatient Surgery Center $750.00 Coinsurance: 80/20% (All other healthcare services are paid under coinsurance) Maximum Out-Of-Pocket (OOP): $4,500.00 6. A patient had cataract surgery at See Clear Outpatient Surgery Center. The allowable for Hawkins Outpatient Surgery Center is $1987.56. How will the payment to the surgery center take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $385.00 Remaining Maximum OOP: $1,987.54 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ Insurance Payment $ $ $ 7. Joey went for his first speech therapy appointment. The allowable $165.32. How will the payment to the speech therapist take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $1,250.00 Remaining Maximum OOP: $455.35 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ Insurance Payment $ $