| Procedure | Amount Billed | Amount the plan approved |
|---|---|---|
| Insertion of needle into vein for collection of blood sample | $11.00 | $1.26 |
| Liver Function Blood test panel | $35.00 | $0.00 DENIED |
| Blood Test, Thyroid stimulating hormone | $64.00 | $0.00 DENIED |
| Complete Blood Cell Count | $30.00 | $0.00 DENIED |
| Blood Test, basic group of blood chemicals | $35.00 | $0.00 DENIED |
| Blood Test (Cholesterol & Triglycerides) | $50.00 | $0.00 DENIED |
| total | $225.00 | $1.26 |