Output  a table with service in first column, location where services are rendered in second (locations can only be ip, op, office, ASC, ER, other), copay in third, co-pay type (day or admission or visit or other) in fourth after identifying the copay for any services in this: "benefits5 your payment  
 when using a participating 
provider3 cyd2 
applies  
preventive health services6   
preventive health services  $0  
california prenatal screening program  $0  
physician services    
primary care office visit  $15/visit   
trio+ specialist care office visit (self -referral)  $30/visit   
other specialist care office visit (referred by pcp)  $30/visit   
physician home visit  $15/visit   
physician or surgeon services in an outpatient facility  $25/visit   
physician or surgeon services in an inpatient facility  $0  
other professional services    
other practitioner office visit  $15/visit   
includes nurse practitioners, physician assistants, and therapists.    
acupuncture services  $15/visit   
chiropractic services  not covered   
teladoc consultation  $0  
family planning    
 counseling, consulting, and education  $0  
 injectable contraceptive, diaphragm fitting, intrauterine 
device (iud), implantable contraceptive, and related 
procedure.  $0  
 tubal ligation  $0  
 vasectomy  $25/surgery   " Limit your response to 200 words.
user