)t 'A. C,):1[1"( tiled Ci :an Amount owed to providers: $5,400 Plan pays $4,260 Patient pays $1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400

or exclusions $200 Total $220 Amount owed to providers: $5,400 Plan pays $4,260 Patient pays $1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400