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Date: <br />Treatment <br />Recommendation Therapy <br />Estimated <br />Charge Per <br />Session or <br />Service <br />(No Print) <br />Insurance <br />Allowed <br />Amount <br />(No Print) <br />Expanded <br />Estimated <br />Total <br />Charges <br />Patient <br />Co-pay <br />Patient Co- <br />insurance <br />Estimated Patient <br />Responsibility <br />12 Chiropractic Manipulative Treatment 3-4 Region - Medicare $65.00 $41.91 $502.92 $502.92 0%$0.00 <br />12 Chiropractic Extremity Adjustment $35.00 $12.87 $154.44 $154.44 0%$0.00 <br />6 Physical Rehabilitation 1 unit $55.00 $31.05 $186.30 $186.30 0%$0.00 <br />1 Established Patient Progress Examination 212 $80.00 $76.03 $76.03 $76.03 0%$0.00 <br />12 FX405 Laser $110.00 $1,320.00 $1,320.00 <br />1.5 Neuropathy Infrared Home Rental - 4 Weeks $294.00 $441.00 $441.00 <br />12 Non-Surgical Spinal Decompression $69.00 $828.00 $828.00 <br />12 Trigenics (Myoneural Manual Medicine) - Intermediate $100.00 $1,200.00 $1,200.00 <br />1 Stick Roller $20.00 $20.00 $20.00 <br />1 Peanut $16.00 $16.00 $16.00 <br />1 Compression Ball $5.60 $5.60 $5.60 <br />1 D-Supreme $87.99 $87.99 $87.99 <br />1 Stabilized R-Lipoic Acid $58.66 $58.66 $58.66 <br />1 Oxi-cell $47.72 $47.72 $47.72 <br /> $4,024.97 <br />Physical Med. Treatment Plan Projections for:7/29/2025 <br />Estimated Patient Portion