an example...where one might be if not for Medicare --  not a social program, i.e., not "on Medicare," getting something for years of taken out monies from taxes on wages, etc.
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Claim processed on 02/25/26
Medicare Summary Notice (MSN)
LABORATORY - BACTERIOLOGY & MICROBIOLOGY (0306)
BACTERIAL COLONY COUNT, URINE (87086)

Provider charged
$104.00
Medicare approved
$104.00
Service (revenue code)


EMERGENCY ROOM - GENERAL CLASSIFICATION (0450)
Procedure description (procedure code)
EMERGENCY DEPARTMENT VISIT WITH HIGH LEVEL OF MEDICAL DECISION MAKING (99285)

Provider charged
$3,691.00
Medicare approved
$3,691.00

Service (revenue code)
LABORATORY - UROLOGY (0307)
Procedure description (procedure code)
MANUAL URINALYSIS TEST WITH EXAMINATION USING MICROSCOPE, AUTOMATED (81001)
Qty
1
Provider charged
$49.00
Medicare approved
$49.00


Service (revenue code)
LABORATORY - BACTERIOLOGY & MICROBIOLOGY (0306)
Procedure description (procedure code)
BACTERIAL CULTURE FOR AEROBIC ISOLATES (87077)
Qty
1
Provider charged
$90.00
Medicare approved
$90.00


Service (revenue code)
LABORATORY - HEMATOLOGY (0305)
Procedure description (procedure code)
BLOOD TEST, CLOTTING TIME (85610)
Qty
1
Provider charged
$70.00
Medicare approved
$70.00

Service (revenue code)
CT SCAN - BODY SCAN (0352)
Procedure description (procedure code)
CT SCAN OF ABDOMEN AND PELVIS WITH CONTRAST (74177)
Qty
1
Provider charged
$2,840.00
Medicare approved
$2,840.00

Service (revenue code)
LABORATORY - GENERAL CLASSIFICATION (0300)
Procedure description (procedure code)
INSERTION OF NEEDLE INTO VEIN FOR COLLECTION OF BLOOD SAMPLE (36415)
Qty
1
Provider charged
$16.00
Medicare approved
$16.00


Service (revenue code)
LABORATORY - IMMUNOLOGY (0302)
Procedure description (procedure code)
BLOOD TYPING FOR RH (D) ANTIGEN (86901)
Qty
1
Provider charged
$103.00
Medicare approved
$103.00


Service (revenue code)
LABORATORY - IMMUNOLOGY (0302)
Procedure description (procedure code)
SCREENING TEST FOR RED BLOOD CELL ANTIBODIES (86850)
Qty
1
Provider charged
$188.00
Medicare approved
$188.00


Service (revenue code)
EMERGENCY ROOM - GENERAL CLASSIFICATION (0450)
Procedure description (procedure code)
INJECTION OF DRUG OR SUBSTANCE INTO VEIN (96374)
Qty
1
Provider charged
$857.00
Medicare approved
$857.00


Service (revenue code)
PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (0636)
Procedure description (procedure code)
INJECTION, CEFTRIAXONE SODIUM, PER 250 MG (J0696)
Qty
4
Provider charged
$4.71
Medicare approved
$4.71


Service (revenue code)
LABORATORY - CHEMISTRY (0301)
Procedure description (procedure code)
BLOOD TEST, BASIC GROUP OF BLOOD CHEMICALS (CALCIUM, TOTAL) (80048)
Qty
1
Provider charged
$147.00
Medicare approved
$147.00

Service (revenue code)
SPECIALTY SERVICES - OBSERVATION HOURS (0762)
Procedure description (procedure code)
HOSPITAL OBSERVATION SERVICE, PER HOUR (G0378)
Qty
5
Provider charged
$1,170.00
Medicare approved
$1,170.00




Service (revenue code)
LABORATORY - CHEMISTRY (0301)
Procedure description (procedure code)
LIPASE (FAT ENZYME) LEVEL (83690)
Qty
1
Provider charged
$115.00
Medicare approved
$115.00


Service (revenue code)
LABORATORY - BACTERIOLOGY & MICROBIOLOGY (0306)
Procedure description (procedure code)
EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTIFUNGAL, ANTIVIRAL), MICRODILUTION OR AGAR DILUTION (87186)
Qty
1
Provider charged
$147.00
Medicare approved
$147.00


Service (revenue code)
LABORATORY - IMMUNOLOGY (0302)
Procedure description (procedure code)
BLOOD GROUP TYPING (ABO) (86900)
Qty
1
Provider charged
$103.00
Medicare approved
$103.00


Service (revenue code)
LABORATORY - CHEMISTRY (0301)
Procedure description (procedure code)
LIVER FUNCTION BLOOD TEST PANEL (80076)
Qty
1
Provider charged
$143.00
Medicare approved
$143.00



Service (revenue code)
LABORATORY - HEMATOLOGY (0305)
Procedure description (procedure code)
COMPLETE BLOOD CELL COUNT (RED CELLS, WHITE BLOOD CELL, PLATELETS), AUTOMATED TEST AND AUTOMATED DIFFERENTIAL WHITE BLOOD CELL COUNT (85025)
Qty
1
Provider charged
$125.00
Medicare approved
$125.00

Service (revenue code)
PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (0636)
Procedure description (procedure code)
LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML (Q9967)
Qty
80
Provider charged
$54.06
Medicare approved
$54.06

Summary
Total amount charged $10,016.77

The amount your provider charged Medicare.

Total Medicare approved $10,016.77

The amount Medicare agreed to pay your provider for the services provided.

Total Medicare paid you $0.00

The amount Medicare paid you directly for the services you got because the provider didn't accept Medicare's approved amount.
Total Medicare paid the facility $1,081.86
The amount Medicare paid the facility.