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SUGANYA BAKTHAVATCHALU 197 HICKORY HEIGHTS DR BRIDGEVILLE, PA 15017-1077
95699515U00 Claim Number: SUGANYA BAKTHAVATCHALU Employee Name: SUGANYA BAKTHAVATCHALU Patient Name: MEMBER Relationship: Patient Account No.: 00452382 Plan Number: AMERINET INC Planholder: MICHAEL M BIANCO, DMD Provider: 05/10/13 Date:
INSURED EXPLANATION OF BENEFITS - THIS IS NOT A BILL Important! Save this statement for tax purposes.
Line No. 1 2 3 4 5 Submitted ADA Codes/Description D9220/GEN ANESTHESIA D7240/IMPACTION FBI D7240/IMPACTION FBI D7240/IMPACTION FBI D9221/ANESTHESIA +15 Alt Code Tooth No. 16 17 32 Date of Service 03/15/13 03/15/13 03/15/13 03/15/13 03/15/13 Submitted Charge 380.00 300.00 300.00 300.00 150.00 1430.00 Considered Charge 218.00 300.00 300.00 300.00 150.00 1268.00 Covered Charge 218.00 300.00 300.00 300.00 150.00 1268.00 Deductible Amount 50.00 Coverage Percent 90% 90% 90% 90% 90% 121.80 Benefit Amount 151.20 270.00 270.00 270.00 135.00 1096.20
TOTALS
50.00
BENEFIT SUMMARY TOTAL BENEFIT PAYABLE......... HIGHER ALLOWABLE.................. PAID BY OTHER INSURANCE..... ADJUSTMENTS............................... TOTAL BENEFIT PAID.................. PATIENT'S RESPONSIBILITY.....
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