Claim CLM-G0101852
$136.59
billed
$122.26
allowed
$76.58
paid
$19.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 3 | 99213 | $107.13 | $53.21 |
| Complete blood count | 85025 | $29.46 | $23.37 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 3 | 99213 | $107.13 | $53.21 |
| Complete blood count | 85025 | $29.46 | $23.37 |