Claim CLM-G0100151
$324.49
billed
$290.30
allowed
$219.65
paid
$8.12
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Spirometry | 94010 | $72.29 | $55.65 |
| Preventive visit, established patient | 99396 | $219.90 | $140.83 |
| Complete blood count | 85025 | $32.30 | $23.17 |