FSA Estimated Expense Calculator

Estimated Annual Income:

Dental Expenses

Exams, Cleaning:

X-rays, Fillings:

Crowns, Root Canals, Dentures:

Orthodontia:

Subtotal:

$0.00

Vision Care Expenses

Exams:

Eyeglasses:

Contact Lenses:

Subtotal:

$0.00

Medical Expenses

Prescription Drugs:

Over-The-Counter Drugs: (See List)

Medical Deductibles and Coinsurance:

HMO Copayments:

Routine Physical Exams:

Other Eligible Expenses: (Examples)

Subtotal:

$0.00

Total Estimated Health Care Expenses:

$0.00

Dependent Care FSA ($5000.00 max)

Day Care Center:

Babysitter:

Nursery School:

Summer Day Camp:

Payment to a Dependent Care Facility or Individual:

Payment to Adult Care Providers:

Other:

Subtotal:

$0.00

Total Estimated Dependent Care Expenses:

$0.00

Estimated Savings

Annual Income With FSA:

$0.00

Annual Income Without FSA:

$0.00

Health Expenses With FSA:

$0.00

Health Expenses Without FSA:

$0.00

Dependent Care Expense With FSA:

$0.00

Dependent Care Expense Without FSA:

$0.00

Taxable Income With FSA:

$0.00

Taxable Income Without FSA:

$0.00

Tax Savings With FSA:

$0.00

Tax Savings Without FSA:

$0.00

This calculator estimates 22% Federal Tax Rate, 7.65% FICA, and 4% State Tax Rate. Your actual savings may vary depending on your own circumstances.