Selected Claim

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Claim Recap

Selected Claim
Status	Finalized		Amount Allowed by Plan	$0.00
Claim Number	30075802-01		PPO Discount	$187.00
Patient Name	TIFFANY		Amount not payable: (ineligible amounts)	$0.00
Date of Service(s)	03 Feb 2003 to 03 Feb 2003		Non-Covered Plan Benefits: (Cosmetic, infertility etc.)	$0.00
Claim Type	MEDICAL		Deductible	$133.00
Total Charges	$320.00		Copayment	$0.00
Primary Carrier Payment: (COB)	$0.00

Payment Check Number   Date of Check Mailed   In the Amount of: $0.00 Withhold Amount: $0.00 Patient Owes: $133.00

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