First Name Last Name Insurance CPT Code Charges Allowed Amount Amount Applied to Deductible Copay Insurance Paid Coinsur
Posted: Wed Dec 22, 2021 9:59 am
First Name
Last Name
Insurance
CPT Code
Charges
Allowed Amount
Amount Applied to Deductible
Copay
Insurance Paid
Coinsurance 20% of Allowed Amount
Patient Responsibility
Pedro
Tanner
BCBS
99291-Critical Care first 30 Minutes
$ 375.00
$ 270.00
$ 100.00
$ -
$ 136.00
$ ____?_____
$ 134.00
Last Name
Insurance
CPT Code
Charges
Allowed Amount
Amount Applied to Deductible
Copay
Insurance Paid
Coinsurance 20% of Allowed Amount
Patient Responsibility
Pedro
Tanner
BCBS
99291-Critical Care first 30 Minutes
$ 375.00
$ 270.00
$ 100.00
$ -
$ 136.00
$ ____?_____
$ 134.00