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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 $57.00 $28.89 $346.68 $346.68 0%$0.00 <br />5 Physical Rehabilitation 1 unit $55.00 $31.05 $155.25 $155.25 0%$0.00 <br />1 Established Patient Progress Examination 212 $80.00 $76.03 $76.03 $76.03 0%$0.00 <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 />Expected from Insurance $1,080.88 Estimated Pat Portion (W/Ded)$2,028.00 <br />Total Insurance Payable after CoPays $0.00 <br />Total Expected from Insurance $1,080.88 <br />Physical Med. Treatment Plan Estimate for:2/23/2026