Billing & Insurance
Total Charges (MTD)
$18,450
Total Payments (MTD)
$15,280
Outstanding Balance
$12,450
Collection Rate
82.8%
Patient Name
Sarah Johnson
Date of Birth
08/14/1988
Primary Insurance
Blue Cross (Active)
Account Balance
$245.00
| Date | Provider | CDT Code | Description | Fee | Ins. Paid | Patient Paid | Adjustment | Balance |
|---|---|---|---|---|---|---|---|---|
| 09/15/2024 | Dr. Michael Chen | D0150 | Comprehensive Oral Exam | $150.00 | $120.00 | $0.00 | $0.00 | $30.00 |
| 09/15/2024 | Dr. Michael Chen | D0210 | Full Mouth X-Ray | $120.00 | $96.00 | $0.00 | $0.00 | $54.00 |
| 09/16/2024 | Dr. Emily Rodriguez | D1110 | Prophylaxis - Adult | $100.00 | $80.00 | $0.00 | $0.00 | $74.00 |
| 09/20/2024 | Dr. Michael Chen | D2394 | Resin-based Composite - Two Surfaces | $280.00 | $224.00 | $0.00 | $0.00 | $130.00 |
| 10/10/2024 | Patient Payment | — | Cash Payment | - | - | $50.00 | $0.00 | $80.00 |
| 10/15/2024 | Insurance Adjustment | — | Insurance Write-off | - | - | $0.00 | -$30.00 | $50.00 |
| 11/05/2024 | Dr. Emily Rodriguez | D3110 | Endodontic Therapy - Anterior | $850.00 | $680.00 | $0.00 | $0.00 | $220.00 |
| 11/12/2024 | Patient Payment | — | Check #4521 | - | - | $100.00 | $0.00 | $120.00 |
| 11/20/2024 | Insurance Claim Payment | — | Claim #CLM-2024-5402 | - | $544.00 | $0.00 | $0.00 | -$424.00 |
| 12/01/2024 | Dr. Michael Chen | D2391 | Resin-based Composite - One Surface | $180.00 | $144.00 | $0.00 | $0.00 | -$244.00 |
| 12/10/2024 | Patient Refund | — | Credit Balance Refund | - | - | -$0.00 | $0.00 | -$244.00 |
| 12/15/2024 | Dr. Emily Rodriguez | D1206 | Fluoride Topical Application | $50.00 | $40.00 | $0.00 | $0.00 | -$194.00 |
| TOTALS | — | — | — | $2,210.00 | $1,764.00 | $150.00 | -$30.00 | $245.00 |
Pending Claims
12
Submitted
8
Accepted
45
Denied
3
| Claim # | Patient | Date | Provider | Amount | Payer | Status | Actions |
|---|---|---|---|---|---|---|---|
| CLM-2024-0521 | Sarah Johnson | 09/15/2024 | Dr. Michael Chen | $270.00 | Blue Cross | Accepted | |
| CLM-2024-0522 | John Martinez | 09/16/2024 | Dr. Emily Rodriguez | $480.00 | Delta Dental | Submitted | |
| CLM-2024-0523 | Emily Watson | 09/18/2024 | Dr. Michael Chen | $650.00 | Cigna | Pending | |
| CLM-2024-0524 | Robert Wilson | 09/20/2024 | Dr. James Lee | $320.00 | Aetna | Denied | |
| CLM-2024-0525 | Lisa Anderson | 09/22/2024 | Dr. Emily Rodriguez | $1,200.00 | Blue Cross | Partial | |
| CLM-2024-0526 | Michael Brown | 09/25/2024 | Dr. Michael Chen | $550.00 | Delta Dental | Accepted | |
| CLM-2024-0527 | Jennifer Davis | 09/28/2024 | Dr. James Lee | $420.00 | Medicaid | Submitted | |
| CLM-2024-0528 | David Taylor | 10/02/2024 | Dr. Emily Rodriguez | $880.00 | Cigna | Draft |
| CDT Code | Description | Category | UCR Fee | PPO Fee | Medicaid Fee |
|---|---|---|---|---|---|
| D0150 | Comprehensive Oral Exam - New Patient | Diagnostic | $150.00 | $120.00 | $100.00 |
| D0210 | Full Mouth - Series of Radiographic Images | Diagnostic | $120.00 | $96.00 | $80.00 |
| D1110 | Prophylaxis - Adult | Preventive | $100.00 | $80.00 | $65.00 |
| D1206 | Fluoride Topical Application | Preventive | $50.00 | $40.00 | $30.00 |
| D2391 | Resin-based Composite - One Surface | Restorative | $180.00 | $144.00 | $120.00 |
| D2394 | Resin-based Composite - Two Surfaces | Restorative | $280.00 | $224.00 | $190.00 |
| D2392 | Resin-based Composite - Three or More Surfaces | Restorative | $350.00 | $280.00 | $235.00 |
| D3110 | Endodontic Therapy - Anterior | Endodontics | $850.00 | $680.00 | $595.00 |
| D4210 | Periodontal Scaling and Root Planing - Per Quadrant | Periodontic | $175.00 | $140.00 | $120.00 |
| D5110 | Complete Denture - Upper | Prosthodontics | $1,200.00 | $960.00 | $840.00 |
| D6010 | Surgical Placement - Implant Body | Orthodontics | $2,000.00 | $1,600.00 | $1,400.00 |
Generate Statements
Recent Statements
December 15, 2024
Sarah Johnson • Account #SJ-2024-0847
$245.00 Due
✓ Sent
December 15, 2024
John Martinez • Account #JM-2024-0832
$120.00 Due
✓ Sent
December 15, 2024
Emily Watson • Account #EW-2024-0821
$0.00 Due
✓ Sent
December 1, 2024
Robert Wilson • Account #RW-2024-0805
$85.50 Due
✓ Sent
November 25, 2024
Lisa Anderson • Account #LA-2024-0793
$320.00 Due
✓ Sent