Claim CLM-G0101632
$227.81
billed
$143.74
allowed
$142.27
paid
$0.28
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Lipid panel | 80061 | $34.86 | $26.31 |
| Office visit, established patient, level 4 | 99214 | $170.49 | $100.92 |
| Complete blood count | 85025 | $22.46 | $15.04 |