Insurance Payment
$376.48
EFT settled
Patient Responsibility
$78.52
Statement queued
Contractual Adjustments
$73.00
CO-45
Remaining Balance
$0.00
Claim closed
Service Line Payments
Claim CLM-2026-0088431
| CPT | Charge | Allowed | Adjustment | Paid | Patient | Reason |
|---|---|---|---|---|---|---|
| 99204 | $245.00 | $212.40 | −$32.60 | $182.40 | $30.00 | CO-45 Contractual |
| 20610 | $198.00 | $172.10 | −$25.90 | $137.68 | $34.42 | CO-45 Contractual |
| 73562 | $85.00 | $70.50 | −$14.50 | $56.40 | $14.10 | CO-45 Contractual |
| Total | $528.00 | $455.00 | −$73.00 | $376.48 | $78.52 |
No denials on this remittance. The AI-applied modifier 25 preserved $182.48 on the E/M line that would otherwise have denied CO-97.
Payment Details
PayerUnitedHealthcare
PlanChoice Plus PPO
Payment methodEFT / ACH
Check / EFT #EFT-556201
Payment date08/09/2026
PatientSarah Johnson
Posted byNetRev auto-posting
Patient Statement
Co-pay collected at visit$30.00
Deductible applied$34.42
Coinsurance$14.10
Statement total$78.52