| Other Payer Allowed | $ |
| allowed amount from other payer's remit |
| Other Payer Paid | $ |
| paid amount from other payer's remit |
| Medicare Allowed | $ |
| allowed amount from Medicare remit |
| Medicare Deductible | $ |
| deductible amount from Medicare remit |
| Medicare Paid | $ |
| paid amount from Medicare remit |
| Actual Charge | $ |
| actual charge from submitted bill |
| | |