03/29/2007 |
MD Example PLLC |
|
MD Example PLLC / Xeni Financial |
Claims Submission: |
|||||||
|
Payer |
Patient Name |
Patient Code |
Claim Number |
Settlement Date |
Total Billed Amount |
Total Payment Amount |
|
HORIZON BLUE CROSS BLUE SHIEL |
FIELDS, MARY |
YHP3HFG17146670 |
7077A |
02/05/2007 |
275.00 |
150.00 |
|
EMPIRE MEDICARE SERVICES |
BROWN, EVELYN |
156430559A |
54925A |
02/06/2007 |
285.00 |
93.65 |
|
EMPIRE MEDICARE SERVICES |
KIRKLAND, LUCY |
593661219A |
55090A |
02/06/2007 |
175.00 |
71.20 |
*** End of Report *** |