16-Nov-2009

Spending by Category
Date Entered between 01/01/2009 and 11/16/2009

3 Sigma Corporation
1985 W Stanfield Rd
Troy, OH 45373

Employer
Category # Claims Submitted Allowed Deductible Co-pay Liability

Division ID
920_Den
01
Claim Ad 1 $50.00 $50.00 $0.00 $0.00 $50.00
Dental 130 $26,520.00 $26,520.00 $1,550.00 $0.00 $22,637.50

02
Dental 26 $11,391.00 $11,366.55 $200.00 $0.00 $7,183.10

04
Dental 4 $683.00 $683.00 $50.00 $0.00 $522.20

4
Dental 16 $4,866.00 $4,866.00 $250.00 $0.00 $3,739.60

920_Ortho
01
Denial 3 $750.00 $750.00 $0.00 $0.00 $0.00
Orthodontics 2 $500.00 $500.00 $0.00 $0.00 $250.00

920_PL06
01
Ambulance 2 $1,946.25 $1,946.25 $0.00 $150.00 $1,796.25
Chiro/Spinal Manipulations 15 $760.00 $553.00 $0.00 $300.00 $253.00
Claim Adjustment 1 $39.33 $39.33 $0.00 $0.00 $39.33
Claim Not Covered 15 $7,440.00 $7,440.00 $0.00 $35.00 $0.00
Denied - Primary carrier filing required 7 $1,746.00 $1,746.00 $340.00 $0.00 $1,166.60
Denied by primary carrier 5 $378.13 $15.00 $0.00 $0.00 $0.00
Durable Medical 5 $1,682.45 $1,321.75 $275.95 $0.00 $865.92
Emergency Room 40 $35,239.39 $20,338.28 $0.00 $1,845.26 $2,037.52
Injections 9 $3,963.60 $2,871.68 $0.00 $160.00 $765.12
Inpatient Medical 20 $123,905.65 $64,387.00 $1,156.67 $0.00 $15,200.16
Maternity 1 $182.00 $126.61 $0.00 $20.00 $106.61
Office Visit 213 $29,505.80 $19,277.01 $0.00 $4,076.51 $12,658.44
OP Diagn 1 $1,581.25 $1,518.00 $250.00 $0.00 $1,014.40
OP Nervous/MH_SA 2 $175.00 $95.00 $0.00 $40.00 $55.00
OP Phys/Occ Therapy 4 $3,777.50 $1,276.44 $551.00 $0.00 $376.51
Outpatient Services 46 $154,273.70 $64,907.73 $3,210.58 $0.00 $18,616.51
Preventive Services 25 $4,520.75 $2,849.44 $0.00 $329.61 $2,501.37
Return Claim 4 ($2,125.03) ($2,125.03) $0.00 $0.00 ($2,125.03)

Nov 16 2009 Spending by Category 1

 3 Sigma Corporation
1985 W Stanfield Rd
Troy, OH 45373

Employer
Category # Claims Submitted Allowed Deductible Co-pay Liability

Division ID
Specialist 17 $2,718.28 $1,735.49 $0.00 $327.19 $1,281.89
Test/Xray/Lab in Office 131 $32,950.03 $14,521.77 $0.00 $0.00 $11,285.58
Testing/Xray/Lab Service 56 $27,315.57 $11,677.05 $3,397.29 $0.00 $4,269.13
Urgent Care Visits 8 $2,312.00 $1,215.00 $0.00 $280.00 $935.00

02
Office Visit 9 $1,424.80 $1,051.89 $0.00 $180.00 $871.89
OP Diagn 1 $1,208.00 $500.16 $250.00 $0.00 $200.13
OP Nervous/MH_SA 5 $840.00 $601.10 $0.00 $100.00 $501.10
Outpatient Services 4 $5,127.00 $2,963.59 $250.00 $0.00 $1,290.87
Preventive Services 1 $152.00 $131.99 $0.00 $20.00 $111.99
Specialist 7 $2,566.00 $1,270.48 $0.00 $120.00 $1,150.48
Test/Xray/Lab in Office 3 $549.23 $248.72 $0.00 $0.00 $248.72
Testing/Xray/Lab Service 1 $156.00 $44.59 $44.59 $0.00 $0.00
Urgent Care Visits 1 $196.00 $126.54 $0.00 $35.00 $91.54

04
Specialist 1 $375.00 $336.25 $0.00 $20.00 $316.25

4
Injections 1 $36.00 $24.60 $0.00 $0.00 $24.60
Inpatient Medical 1 $36,559.32 $8,093.00 $0.00 $0.00 $1,390.78
Office Visit 12 $1,568.58 $1,058.98 $0.00 $240.00 $818.98
OP Diagn 2 $3,084.11 $1,532.93 $0.00 $0.00 $1,226.35
Outpatient Services 9 $30,488.17 $12,025.70 $500.00 $0.00 $6,135.58
Return Claim 1 ($35.99) ($35.99) $0.00 $0.00 ($35.99)
Specialist 2 $190.00 $111.98 $0.00 $40.00 $71.98
Test/Xray/Lab in Office 6 $1,766.13 $718.14 $0.00 $0.00 $718.14
Testing/Xray/Lab Service 1 $19.50 $4.43 $4.43 $0.00 $0.00

920_Vis
01
Claim Adjustment 1 $73.50 $73.50 $0.00 $0.00 $73.50
Corrective Eyewear 24 $4,607.40 $4,485.00 $0.00 $480.00 $2,985.28
Denial 1 $424.00 $424.00 $0.00 $0.00 $0.00
Vision / Eye Exam 19 $1,790.99 $1,602.11 $0.00 $380.00 $922.00

02
Corrective Eyewear 1 $149.92 $149.92 $0.00 $20.00 $129.92
Vision / Eye Exam 2 $396.00 $396.00 $0.00 $40.00 $110.00

4
Corrective Eyewear 2 $1,047.00 $952.60 $0.00 $40.00 $200.00

920-OON_PL06
01
Ambulance 1 $933.55 $933.55 $500.00 $0.00 $260.13

Nov 16 2009 Spending by Category 2

 3 Sigma Corporation
1985 W Stanfield Rd
Troy, OH 45373

Employer
Category # Claims Submitted Allowed Deductible Co-pay Liability

Division ID

Totals: 928 $574,739.86 $302,294.11 $12,780.51 $9,278.57 $127,295.93

Nov 16 2009 Spending by Category 3