Claim CLM-G0100169
$606.79
billed
$540.44
allowed
$376.44
paid
$60.80
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 4 | 99214 | $192.93 | $88.72 |
| Telehealth visit, level 3 | 99213 | $148.74 | $94.52 |
| Office visit, new patient | 99204 | $265.12 | $193.20 |