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Repricing Statement
Repricing Statement |
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Medical Bill Repricing Statement Your Company Name Employer/Client: Patient Name: Provider: Bill Date: Claim Number: ADAIR COUNTY
JOHNSON, JOHN J
ADAIR CHC DBA MEMORIAL H
07/12/2004
WC052510
 CODE
DATE
CODE DESCRIPTION
BILLED
STATE
PROV DISC
APPLY
00000
07/12/2004 MED SUR SUPPLIES
$5.50 $5.50 $5.50 $5.50 71020
07/12/2004 RADIOLOGIC EXAMINATION CHST 2 VIEWS FRNTL⪫
$100.00 $33.55 $33.55 $33.55 72050
07/12/2004 RADIOLOGIC EXAMINATION SPINE CERV; MINI 4 VIEWS
$125.00 $54.75 $54.75 $54.75 72100
07/12/2004 RADIOLOGIC EXAM SPINE LUMBOSACRAL; TWO/3 VIEWS
$100.00 $35.32 $35.32 $35.32 99281
07/12/2004 EMERG DEPT VISIT E&M SELF LIMITED/MINOR
$80.00 $34.82 $34.82 $34.82 99282
07/12/2004 EMERG DEPT VISIT E&M LOW-MODERATE SEVERITY
$60.00 $56.15 $56.15 $56.15 $470.50 $220.09 $220.09 $220.09 Bill Totals:
Report Date: 10/12/2004
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