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| 97128 | ULTRSOUND | $26.00 | $26.00 | 1232 | Timed 15 Minutes | 3342 | Maxmill Revenue Center | 8978 | Active | ||||||||||||||||||||||||||||||
| 23128 | XRAY | $10.00 | $10.00 | 3232 | Timed 30 Minutes | 2323 | Maxmill Revenue Center | 8780 | Active |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 97128 | ULTRSOUND | $26.00 | $26.00 | 1232 | Timed 15 Minutes | 3342 | Maxmill Revenue Center | 8978 | Active | ||||||||||||||||||||||||||||||
| 23128 | XRAY | $10.00 | $10.00 | 3232 | Timed 30 Minutes | 2323 | Maxmill Revenue Center | 8780 | Active |
| Code | Description | Is Excluded |
|---|---|---|
| 96 | Non-covered charge(s) | |
| A1 | Claim denied charge(s) | |
| 96 | Non-covered charge(s) | |
| A1 | Claim denied charge(s) |
| Appointment Time | Patient | Arrival Time | |
|---|---|---|---|
| 9:00 AM | Smith, Suzie | 8:47 AM | |
| 9:00 AM | Doe, John | 9:01 AM |
8/12/1915 (age: 3), 602-230-0956(m), john.smith@gmail.com
8/12/1915 (age: 3), 602-230-0956(m), john.smith@gmail.com
8/12/1915 (age: 3), 602-230-0956(m), john.smith@gmail.com
| CPT | Mod1 | Mod2 | Description | Insurance Name | Dx1 | Dx2 | Dx2 | Dx4 | Dx5 | Dx6 | Dx7 | Dx8 | Units | Charge Amt | Pat Pay Amt | Ins Pay Amt | Ins Adj Amt | Balance | Billing Status |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 97140 | MANUAL THERAPY | ORTHONET HEALTHNET | A000 | 1 | $45.00 | $0.00 | $0.00 | $0.00 | $45.00 |
| Payment Code | Pay Amt | Adj Code | Adj Amt | Deposit Date | Insurance Code | Transfer Amt | Transfer Insurance Code | Check Number | Reason | Date Posted |
|---|---|---|---|---|---|---|---|---|---|---|
| PIOF - PATIENT PD IN OFFICE | $68.00 | $0.00 | 09/06/2007 | 0 - American National InsuranceCP | $0.00 | 02/21/2008 |
| Date of Service | Claim Date | Insurance Name | Insurance Code | CPT | Units | Billed Amount | RunNum | Format Type | Insurance Type | Claim Code | Claim Action | Late Reason | Format Number |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No Records Available |