| # | Provider / Patient | Service Date | Service Type | Billed | Insurance Paid | You Owe (EOB) | You Owe (Bill) | Match? | Status | Notes |
|---|---|---|---|---|---|---|---|---|---|---|
| EX | City General Hospital Pat: Jane Doe |
01/15/26 | ER Visit | $4,200 | $3,780 | $420 | $420 | ✅ | Paid | Met deductible with this visit |
| EX | Valley Radiology Pat: Jane Doe |
01/22/26 | MRI | $2,800 | $2,240 | $560 | $560 | ✅ | Paid | |
| EX | Dr. Patel — Cardiology Pat: Jane Doe |
02/03/26 | Follow-up | $350 | $280 | $70 | $70 | ✅ | Paid | |
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| TOTALS |
| Category | Annual Limit | Met So Far | Remaining | % Complete |
|---|---|---|---|---|
| EX Deductible | $3,000 | $1,050 | $1,950 | 35% |
| EX Out-of-Pocket Max | $7,500 | $1,050 | $6,450 | 14% |
| Deductible | ||||
| Out-of-Pocket Max |
| Date Paid | Provider | Amount | Method | Confirmation # | HSA/FSA? |
|---|---|---|---|---|---|
| EX 02/15/26 | City General Hospital | $420 | Credit Card | #CHG-8821 | No |
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