Provider Utilization
By Group Code Report Date: 11/06/2003
By Plan Report Period: 10/01/2003 - 10/31/2003 Paid
By Location  

Provider		 Provider
Tin
Suffix
Address
City
State
Zip
Claims
Charges
Disallowed
Discount
Paid
Group: 99999
Benefit Type: D
  DR SMITH DDS 123456789 02 123 NOWHERE ST MONTEREY CA 93940 3 $420.00 $20.00 $.00 $400.00
DR SMITH DDS 123456789 02 123 NOWHERE ST SALINAS CA 93905 3 $1,528.00 $12.40 $.00 $1,000.00
DR SMITH DDS 123456789 01 123 NOWHERE ST MONTEREY CA 93940 4 $374.00 $187.00 $.00 $187.00
DR SMITH DDS 123456789 01 123 NOWHERE ST CARMEL CA 93923 2 $843.00 $53.00 $.00 $639.60
DR SMITH DDS 123456789 01 123 NOWHERE ST SALEM OR 97302 1 $872.00 $125.00 $.00 $618.00
DR SMITH DDS 123456789 02 123 NOWHERE ST SALINAS CA 93901 1 $70.00 $.00 $.00 $36.00
DR SMITH DDS 123456789 02 123 NOWHERE ST SALINAS CA 93906 2 $462.00 $22.00 $.00 $352.00
DR SMITH DDS 123456789 01 123 NOWHERE ST SEASIDE CA 93955 4 $1,715.00 $168.00 $.00 $1,336.00
DR SMITH DDS 123456789 01 123 NOWHERE ST CARMEL VALLEY CA 93924 1 $177.00 $15.00 $.00 $109.60
DR SMITH DDS 123456789 02 123 NOWHERE ST SAND CITY CA 93955 1 $869.00 $3.00 $.00 $690.00
 
Total Ben Type: D           22 $7,330.00 $605.40 $.00 $5,368.20
 
Benefit Type: M
_ . . . . . . 29 $13,623.41 $10,122.50 $517.13 $2,217.82
DR JONES MD 123456789 06 456 ANYWHERE AVE SAN FRANCISCO CA 123456789 1 $952.00 $952.00 $.00 $.00
DR JONES MD 123456789 06 456 ANYWHERE AVE SANTA ANA CA 92705 1 $11,764.00 $11,764.00 $.00 $.00
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 123456789 4 $876.00 $126.00 $.00 $600.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 123456789 1 $427.00 $.00 $62.00 $292.00
DR JONES MD 123456789 0A 456 ANYWHERE AVE SALINAS CA 93901 1 $89.00 $89.00 $.00 $.00
DR JONES MD 123456789 0R 456 ANYWHERE AVE MONTEREY CA 93940 1 $70.00 $.00 $7.00 $48.00
DR JONES MD 123456789 ni 456 ANYWHERE AVE SAN FRANCISCO CA 94144 1 $971.00 $.00 $194.20 $776.80
DR JONES MD 123456789 07 456 ANYWHERE AVE ORANGE CA 92669 1 $980.00 $.00 $.00 $980.00
DR JONES MD 123456789 nS 456 ANYWHERE AVE SAN FRANCISCO CA 123456789 1 $456.00 $.00 $.00 $.00
DR JONES MD 123456789 01 456 ANYWHERE AVE CARMEL CA 93923 1 $796.42 $796.42 $.00 $.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940 1 $117.32 $.00 $.00 $102.32
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940-4507 1 $257.00 $257.00 $.00 $.00
DR JONES MD 123456789 1d 456 ANYWHERE AVE SAN FRANCISCO CA 94139 21 $30,658.55 $19,495.20 $.00 $8,721.31
DR JONES MD 123456789 0I 456 ANYWHERE AVE SALINAS CA 93912 1 $.00 $.00 $.00 $.00
DR JONES MD 123456789 09 456 ANYWHERE AVE SALINAS CA 123456789 3 $262.00 $.00 $.00 $217.00
DR JONES MD 123456789 0J 456 ANYWHERE AVE MONTEREY CA 93940 1 $100.00 $.00 $34.63 $52.30
DR JONES MD 123456789 0N 456 ANYWHERE AVE HOLLISTER CA 95024 1 $127.00 $.00 $10.00 $102.00
DR JONES MD 123456789 tj 456 ANYWHERE AVE SAN FRANCISCO CA 94144 1 $610.00 $.00 $368.43 $241.57
DR JONES MD 123456789 1V 456 ANYWHERE AVE SALINAS CA 93902 2 $161.00 $.00 $58.65 $87.35
DR JONES MD 123456789 04 456 ANYWHERE AVE TRACY CA 123456789 2 $232.00 $138.00 $.00 $.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 123456789 2 $2,450.00 $.00 $.00 $2,390.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940 3 $3,875.00 $3,875.00 $.00 $.00
DR JONES MD 123456789 0E 456 ANYWHERE AVE PALO ALTO CA 94304 1 $85.00 $85.00 $.00 $.00
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 93940 1 $115.00 $.00 $.00 $100.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940 1 $43.00 $.00 $.00 $34.40
DR JONES MD 123456789 $, 456 ANYWHERE AVE SAN FRANCISCO CA 94144 1 $75.00 $.00 $.00 $75.00
DR JONES MD 123456789 0x 456 ANYWHERE AVE SALINAS CA 93906 1 $93.00 $.00 $.00 $78.00
DR JONES MD 123456789 6W 456 ANYWHERE AVE SALINAS CA 123456789 1 $126.00 $.00 $.00 $111.00
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 123456789 1 $198.00 $.00 $.00 $183.00
DR JONES MD 123456789 01 456 ANYWHERE AVE SAN FRANCISCO CA 94144 1 $869.46 $869.46 $.00 $.00
DR JONES MD 123456789 1k 456 ANYWHERE AVE SAN FRANCISCO CA 94144 3 $2,608.28 $.00 $608.52 $1,999.76
DR JONES MD 123456789 02 456 ANYWHERE AVE PACIFIC GROVE CA 93950 1 $86.00 $.00 $.00 $71.00
DR JONES MD 123456789 0E 456 ANYWHERE AVE MONTEREY CA 93940 1 $102.00 $.00 $.00 $87.00
DR JONES MD 123456789 02 456 ANYWHERE AVE CARMEL CA 93923 1 $178.00 $178.00 $.00 $.00
DR JONES MD 123456789 04 456 ANYWHERE AVE MONTEREY CA 93940 1 $45.00 $.00 $4.45 $25.55
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940 2 $260.00 $.00 $39.36 $190.64
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 93940 2 $400.00 $.00 $59.02 $325.98
DR JONES MD 123456789 21 456 ANYWHERE AVE CYPRESS CA 90630 1 $202.70 $.00 $45.25 $157.45
DR JONES MD 123456789 01 456 ANYWHERE AVE CARMEL VALLEY CA 93924 1 $96.00 $.00 $5.78 $75.22
DR JONES MD 123456789 03 456 ANYWHERE AVE MONTEREY CA 93940-4565 1 $415.00 $180.00 $70.08 $131.94
DR JONES MD 123456789 02 456 ANYWHERE AVE SALINAS CA 93901 1 $89.00 $.00 $.00 $74.00
DR JONES MD 123456789 0E 456 ANYWHERE AVE PALO ALTO CA 94304-1512 1 $105.00 $.00 $21.00 $84.00
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 93940 1 $745.00 $.00 $.00 $447.00
DR JONES MD 123456789 01 456 ANYWHERE AVE SALINAS CA 123456789 1 $120.00 $.00 $.00 $105.00
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 93940 2 $295.00 $.00 $30.13 $225.42
DR JONES MD 123456789 -T 456 ANYWHERE AVE SAN FRANCISCO CA 94144-0001 1 $458.00 $.00 $281.00 $177.00
DR JONES MD 123456789 04 456 ANYWHERE AVE MONTEREY CA 93942 1 $85.00 $.00 $.00 $70.00
DR JONES MD 123456789 0g 456 ANYWHERE AVE SAN FRANCISCO CA 94160 1 $123.25 $123.25 $.00 $.00
DR JONES MD 123456789 X> 456 ANYWHERE AVE SAN FRANCISCO CA 94144 1 $53.00 $.00 $10.60 $42.40
DR JONES MD 123456789 >S 456 ANYWHERE AVE SAN FRANCISCO CA 94114 1 $49,745.49 $.00 $26,098.36 $23,647.13
DR JONES MD 123456789 02 456 ANYWHERE AVE MONTEREY CA 93940 1 $400.00 $.00 $14.78 $370.22
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 93940 3 $342.00 $.00 $.00 $297.00
DR JONES MD 123456789 01 456 ANYWHERE AVE MONTEREY CA 123456789 1 $330.00 $.00 $29.67 $285.33
DR JONES MD 123456789 1I 456 ANYWHERE AVE MONTEREY CA 93940 2 $418.00 $79.00 $54.75 $254.25
DR JONES MD 123456789 1J 456 ANYWHERE AVE MONTEREY CA 93940 2 $210.00 $.00 $15.00 $165.00
DR JONES MD 123456789 02 456 ANYWHERE AVE TRACY CA 123456789 1 $66.00 $.00 $10.00 $41.00
DR JONES MD 123456789 02 456 ANYWHERE AVE SACRAMENTO CA 95851 8 $962.35 $213.50 $173.47 $416.38
DR JONES MD 123456789 09 456 ANYWHERE AVE PALO ALTO CA 94304 2 $114.00 $114.00 $.00 $.00
DR JONES MD 123456789 0c 456 ANYWHERE AVE SALINAS CA 93906 1 $282.00 $.00 $177.00 $90.00
DR JONES MD 123456789 09 456 ANYWHERE AVE SALINAS CA 123456789 1 $100.00 $.00 $.00 $100.00
 
Total Ben Type: M           136 $130,895.23 $49,457.33 $29,000.26 $47,365.54
 
Benefit Type: P
PBM ABC 123456789 02 PO BOX 123456 ATLANTA GA 30394-5551 3 $12,194.62 $.00 $.00 $12,194.62
 
Total Ben Type: P           3 $12,194.62 $.00 $.00 $12,194.62
Total Group: 99999           161 $150,419.85 $50,062.73 $29,000.26 $64,928.36
 

Provider		 Provider
Tin
Suffix
Address
City
State
Zip
Claims
Charges
Disallowed
Discount
Paid
 
TOTAL               161 $150,419.85 $50,062.73 $29,000.26 $64,928.36
 
Provider Utilization
Requestor: John Employer
Report Date: 11/06/2003
Sort fields: Selected values:
Group 99999
Benefit Type(s): ALL
Date: Paid
Report Period: 10/01/2003 - 10/31/2003
Report by: All