 |
| |
| Service
From |
Provider
Name |
Total
Charge |
Amount Blue Cross
Paid |
Notes |
| 12/11/03 |
UCI
Medical Center |
$77.00 |
$46.20 |
surg.
Visit |
| 9/22/03 |
UCI
Medical Center |
$77.00 |
$46.20 |
surg.
Visit |
| 9/17/03 |
UCI
Medical Center |
$44,738.00 |
$3,060.00 |
hospital/surg |
| 9/20/03 |
UCI
Radiology |
$60.00 |
$10.99 |
chest
xray |
| 9/18/03 |
UCI
Radiology |
$230.00 |
$43.08 |
leak
test |
| 9/18/03 |
University
Surgeons |
$5,500.00 |
$1,309.76 |
nguyen |
| 9/17/03 |
University
Anesthesia |
$1,680.00 |
$880.20 |
anesth |
| 9/17/03 |
University
Surgeons |
$1,375.00 |
$261.46 |
assistant
surg |
| 9/10/03 |
UCI
Radiology |
$60.00 |
$10.99 |
pre
op xray |
| 9/10/03 |
UCI
Medical Center |
$582.00 |
$102.98 |
pre
op labs |
| 8/28/03 |
UCI
Medical Center |
$144.00 |
$65.46 |
surg.
Visit |
| 8/7/03 |
UCI
Medical Center |
$77.00 |
$46.20 |
surg.
Visit |
| 8/7/03 |
University
Surgeons |
$70.00 |
$44.62 |
surg.
Visit |
| 7/23/03 |
Relationship
Focus |
$160.00 |
$80.80 |
psych
eval |
| 7/19/03 |
St
Jude Medical Center |
$3,140.00 |
$819.77 |
sleep
study |
| 7/14/03 |
St
Jude Hospital |
$131.00 |
$40.60 |
pcp
labs |
| 7/1/03 |
St
Jude Hospital |
$100.00 |
$27.26 |
pcp
visit |
| 6/30/03 |
University
Surgeons |
$150.00 |
$100.16 |
surg
consult |
| 6/30/03 |
UCI
Medical Center |
$77.00 |
$46.20 |
surg.
Visit |
| 6/30/03 |
UCI
Medical Center |
$77.00 |
$0.00 |
surg.
Visit |
|
TOTAL |
$58,505.00 |
$7,042.93 |
|
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