Claim CLM-2026960007
$50,478.73
billed
$46,309.26
allowed
$40,268.92
paid
$6,040.34
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 | $9,046.75 | $6,332.72 |
| Ultrasound scan for fetal viability (procedure) | 169230002 | $4,740.21 | $3,318.15 |