Can someone help me with this chart

HMO pay? What does the patient owe? 4. Lisa Perez met and her coinsurance was seen i n your office twice last fall. Her deductible has been is 85-15. In October, she was seen for uenza accination, and her insurance company was billed $13.00 for the vacc and $9.00 for the administration for her indemnity being a covered service, but it does not include the actual vaccine. In December, Lisa had an office visit and had blood drawn to be sent to an outside lab; bo f the vaccine. Lisa's schedule of benefits insurance plan lists the influenza administration as th these services are included in the schedule of benefits. The ledger card/patient statement shows the dates and charges for services; you need to calculate each amount paid by the insurance P and enter it on the ledger card/patien running balance. lan t statement. Remember to keep a Lisa Perez 478 Third Street Allentown, PA 18102 610-555-1937 Universal Health Chart #753159 Date Description Provider Charge Payment Balance Influenza virus vaccine Administration influenza sek sek 13.00 9.00 10/23 Ins rej, serv, not covered 0/23 Plan payment 217 OVloutpt. Est 99213 12/17 Drawing blood fee 65.00 5.00 12/27Plan payment OV 12/27 Plan payment veinpuncture