Claim CLM-G0117166
$331.14
billed
$217.72
allowed
$191.01
paid
$4.10
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 3 | 99213 | $162.84 | $73.34 |
| Office visit, established patient, level 4 | 99214 | $168.30 | $117.67 |