POS: {{ billingMiscellanous.typeOfBillOrFrequency }}     Frequency: {{ billingMiscellanous.frequency }}

DX:    1:   {{ dx[0] }}   2:   {{ dx[1] }}   3:   {{ dx[2] }}   4:   {{ dx[3] }}   5:   {{ dx[4] }}   6:   {{ dx[5] }}   7:   {{ dx[6] }}  

Service Lines

Total Charges:    ${{ billingMiscellanous.totalClaimCharges }}       

Primary: {{ohiInfo.primaryOhi.otherPayerName}}    Seconday: {{ohiInfo.secondaryOhi.otherPayerName}}    Tertiary: {{ohiInfo.isTertiaryOhi}}

Claim Level Adjustments: Primary Paid Adj. Adj. Amount Secondary Paid Adj. Adj. Amount Tertiary Paid Adj. Adj. Amount
${{ohiInfo.primaryOhi.payerPaidAmount}} {{claim.adjustmentCode}} ${{claim.adjustmentAmount}} ${{ohiInfo.primaryOhi.payerPaidAmount}} {{claim.adjustmentCode}} ${{claim.adjustmentAmount}}
Line # Svc. From Amount PROC Primary Paid Adj. Adj. Amount Secondary Paid Adj. Adj. Amount Tertiary Paid Adj. Adj. Amount
{{line.lineNumber}} {{line.beginDateOfService}} {{line.charge}} {{line.ohiModifiers}} ${{line.primaryPayerPaidAmount}} {{line.primaryPayerProcedureCode}} ${{line.primaryServiceLineAdjustment}} ${{line.secondaryPayerPaidAmount}} {{line.secondaryPayerProcedureCode}} ${{line.secondaryServiceLineAdjustment}}
Remittance Remark Codes: {{remarkCode.code }} {{remarkCode.code }}
Miscellaneous Provider Accepted Assignment: {{billingMiscellanous.providerAcceptsAssignment}}      Patient Paid: {{billingMiscellanous.patientPaidAmount}}