| Line | Charge | Paid | CO-45 | Patient | Ties |
|---|---|---|---|---|---|
| D0120Exam | 65.00 | 48.00 | 17.00 | 0.00 | |
| D1110Cleaning | 120.00 | 92.00 | 28.00 | 0.00 | |
| D0274Bitewings | 85.00 | 49.60 | 23.00 | 12.40 | |
| D2392Filling | 240.00 | 104.00 | 60.00 | 76.00 | |
| Claim | 510.00 | 293.60 | 128.00 | 88.40 |
384.00 + 310.00 + 384.00 = 1,078.00 against a 1,150.00 charge. $72.00 has no adjustment code. Not posted.
Held for review