Claim CLM-G0114251
$386.82
billed
$308.90
allowed
$257.81
paid
$12.64
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Preventive visit, established patient | 99396 | $174.93 | $130.34 |
| Spirometry | 94010 | $111.56 | $56.33 |
| Spirometry | 94010 | $100.33 | $71.14 |