Claim CLM-G0114252
$217.94
billed
$121.40
allowed
$158.93
paid
$0.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 4 | 99214 | $217.94 | $158.93 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 4 | 99214 | $217.94 | $158.93 |