Claim CLM-G0140973
$239.16
billed
$208.88
allowed
$122.84
paid
$17.87
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Physical therapy, therapeutic exercise | 97110 | $61.29 | $35.48 |
| Chest radiograph, 2 views | 71046 | $129.84 | $63.19 |
| Influenza vaccine administration | 90686 | $48.03 | $24.17 |