To specify allowances, charges, or services
| Position | Element | Name | Type | Min/Max | Repeat | |
|---|---|---|---|---|---|---|
| 1 | 248 | Allowance or Charge Indicator Code | Mandatory | ID | 1/1 | AtMax 1 |
| 2 | 559 | Agency Qualifier Code | Rel | ID | 2/2 | AtMax 1 |
| 3 | 560 | Special Services Code | Rel | ID | 2/10 | AtMax 1 |
| 4 | 331 | Allowance or Charge Method of Handling Code | Mandatory | ID | 2/2 | AtMax 1 |
| 5 | 341 | Allowance or Charge Number | Opt | Alphanumeric | 1/16 | AtMax 1 |
| 6 | 359 | Allowance or Charge Rate | Opt | Decimal | 1/15 | AtMax 1 |
| 7 | 360 | Allowance or Charge Total Amount | Opt | Number | 1/15 | AtMax 1 |
| 8 | 378 | Allowance/Charge Percent Qualifier | Opt | ID | 1/1 | AtMax 1 |
| 9 | 332 | Percent, Decimal Format | Rel | Decimal | 1/6 | AtMax 1 |
| 10 | 380 | Quantity | Rel | Decimal | 1/15 | AtMax 1 |
| 11 | 355 | Unit or Basis for Measurement Code | Rel | ID | 2/2 | AtMax 1 |
| 12 | 380 | Quantity | Rel | Decimal | 1/15 | AtMax 1 |
| 13 | 352 | Description | Rel | Alphanumeric | 1/80 | AtMax 1 |
| 14 | 150 | Special Charge or Allowance Code | Rel | ID | 3/3 | AtMax 1 |
| 15 | 822 | Source Subqualifier | Opt | Alphanumeric | 1/15 | AtMax 1 |
| 16 | 662 | Relationship Code | Opt | ID | 1/1 | AtMax 1 |
| 17 | 355 | Unit or Basis for Measurement Code | Opt | ID | 2/2 | AtMax 1 |