Claim CLM-2026146005
$38,955.48
billed
$35,707.87
allowed
$31,050.32
paid
$4,657.55
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Prenatal initial visit (regime/therapy) | 424441002 | $0.00 | $0.00 |
| Normal pregnancy (finding) | 72892002 | $0.00 | $0.00 |
| Standard pregnancy test (procedure) | 252160004 | $2,261.69 | $1,583.18 |
| Ultrasound scan for fetal viability (procedure) | 169230002 | $4,049.70 | $2,834.79 |