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| Service Item | Charge Amount | Adjustment Amount | Patient Amount | 
|---|---|---|---|
| 99212 | $200.00 | $100 | $100 | 
| 99212 | $200.00 | $100 | $100 | 
| Service Item | Charge Amount | Adjustment Amount | Patient Amount | Calculation | 
|---|---|---|---|---|
| 99212 | $200.00 | $195 | $5 | ($200.00/$400.00)*$10.00 = $5 | 
| 99212 | $200.00 | $195 | $5 | ($200.00/$400.00)*$10.00 = $5 |