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Claim Detail
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Selected Claim |  |
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| DR. MILLFORD | |||||||||
| OFFICE VISIT | 19-Dec-1999 to 19-Dec-1999 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $79.00 | $41.21 | $0.00 | DF | $20.00 | $17.79 | $0.00 | $0.00 | 80.0 % | $17.79 |
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Totals | |
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| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amt Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $79.00 | $41.21 | $0.00 | N/A | $20.00 | $17.79 | $0.00 | $0.00 | N/A | $17.79 |
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