Benefit Details
Considered Charge:
$12,000.00
Allowed:
$11,990.00
Disallow:
$10.00
Deductible:
$4,500.00
Copay:
$0.00
Coinsurance:
$4,491.00
COB Adjustments:
$0.00
Benefit:
$2,999.00
Considered Allowed:
$11,990.00
Considered Benefit:
$2,999.00
Allowed Units:
1
Withhold:
$0.00
Patient Liability Disallow:
$0.00
Total Patient Liability:
$8,991.00
HRA Paid:
$0.00
FSA Paid:
$0.00
Primary Disallow:
PDC - Provider
Explanation Capitation:
Agreement Discount. Noncapitated
Indicator Overrides:
Yes