TOB: 11/1

Statement Covers Period Admission ADHR DHR Stat. Admit DX Reason
01/01/2017 to 01/01/2018 01/01/2017 13:00 13:00 30 123.45 UNK
DX:     1:   A12.34 2:   B56.78 3:   C56.78 4:   D56.78 5:   E56.78 6:   F56.78 7:  G56.78 8:   H56.78 9:   I56.78 10:   J56.78 11:   K56.78
E:     1:   A12.34 2:   B56.78 3:   C56.78 4:   D56.78 5:   E56.78 6:   F56.78 7:  G56.78 8:   H56.78
PX:     1:   A12.34 2:   B56.78 3:   C56.78 4:   D56.78 5:   E56.78 6:   F56.78 7:  G56.78 8:   H56.78 9:   I56.78 10:   J56.78 11:   K56.78

Service Lines

Total Charges:    $99999.99

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Claim Level Adjustments: Primary Paid Adj. Adj. Amount Secondary Paid Adj. Adj. Amount Tertiary Paid Adj. Adj. Amount
${{ohiInfo.primaryOhi.payerPaidAmount}} {{claim.adjustmentCode}} ${{claim.adjustmentAmount}} ${{ohiInfo.primaryOhi.payerPaidAmount}} {{claim.adjustmentCode}} ${{claim.adjustmentAmount}}
Line # Svc. From Amount PROC Primary Paid Adj. Adj. Amount Secondary Paid Adj. Adj. Amount Tertiary Paid Adj. Adj. Amount
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Remittance Remark Codes: {{remarkCode.code }} {{remarkCode.code }}
Miscellaneous Provider Accepted Assignment: {{billingMiscellanous.providerAcceptsAssignment}}      Patient Paid: {{billingMiscellanous.patientPaidAmount}}