| Expense | Amount billed | Amount Insurance Pays | Amount Insured Owes |
|---|---|---|---|
| Deductible | $500 | $0 | $500 |
| Hospital Room & Board including
Laboratory Tests, X-rays, Prescription Medical and other miscellaneous |
$2,000/day for 3 days | Up to $1,300/day, 3 day maximum | $2,100 |
| Surgical Treatment | $6,000 | $3,000 | $3,000 |
| Prescription Drugs | $600 | $100 | $500 |
| Diagnostic X-rays & Lab Services | $400 | $400 | $0 |
| Total: | $13,500 | $7,400 | $6,100 |
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