Claim CLM-G0109275
$277.34
billed
$177.38
allowed
$174.65
paid
$0.43
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Complete blood count | 85025 | $23.96 | $17.74 |
| Chest radiograph, 2 views | 71046 | $156.42 | $85.77 |
| Physical therapy, therapeutic exercise | 97110 | $96.96 | $71.14 |