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Service Cost (fee schedule) Allowable Amount Deductible ($500 per year) Coinsurance (20%) Copayment ($25 per visit) Total insurance pays Total Patient responsibility Write Off Physician

Service Cost (fee schedule) Allowable Amount Deductible ($500 per year) Coinsurance (20%) Copayment ($25 per visit) Total insurance pays Total Patient responsibility Write Off Physician Visit $200.00 $150.00 $50.00 $ 15.00 $ 25.00 $ 60.00 $ 90.00 $ 50.00 CT Scan $1,600.00 $1,200.00 Flu Vaccine $30.00 $20.00 Pneumonia Vaccine $30.00 $25.00 Total Amount ?

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