Information: This is aninpatientbillcreated on March 1, 2019and the patient has Medicare as his primary insurance. Complete the table below - fill in correct values for Xs. 5 bed ward for 10 days at $425.00 per day ICU Surgical Unit 2 days at $135.00 per day (Medicare will not cover $55.00 of the ICU total) Clinical lab tests totaling $122.90 Bacteriological tests totaling $50.10 Surgical supplies totaling $78.50 Medical supplies totaling $22.10 Pharmacy totaling $744.00 Anesthesia for $447.00 Minor surgery room charge for $623.00 Echocardiography test at $178.30 (Medicare will only cover $163.30) Cytology test totaling $223.80 (Medicare will only cover $137.30) 2 pints of Packed Red Blood Cells at $75.00 each Note: In row 23, the total for "47. Total Charges" should have the total of any non-covered charges subtracted out as these will not be paid. 42. Rev CD 43. Description 44. HCPCS/Rate 45. Serv Date 46. Serv Units 47. Total Charges 48. Non-cov Charges 1 0150 ROOM-BOARD/WARD 425.00 10 4250.00 2 0201 ICU/SURGICAL 135.00 2 270.00 55.00 3 0250 PHARMACY 744.00 4 0270 MED-SUR SUPPLIES 100.60 5 0300 LAB 122.90 6 0306 BACT & MICRO TESTS 50.10 7 X CYTOLOGY TESTS X X 8 X OR/MINOR X 9 X ANESTHESIA X 10 X BLOOD/PKD RED X X 11 X ECHOCARDIOLOGY X X 23 X PAGE_1_OF _1_ 030107 TOTALS X X