| Service Date | Provider | Service Description | Billed | Allowed | Plan Paid | Your Responsibility |
|---|---|---|---|---|---|---|
| {{ visit_date }} | {{ provider_name }} | {{ procedure_description }} ({{ procedure_code }}) | ${{ billed_amount }} | ${{ allowed_amount }} | ${{ plan_paid }} | ${{ member_responsibility }} |
| Total Billed | ${{ billed_amount }} |
| Plan Discount | ${{ discount_amount }} |
| Plan Paid | ${{ plan_paid }} |
| Amount You Owe | ${{ member_responsibility }} |
Questions? Call Member Services at 1-800-555-HEALTH or visit myaevara.com