Claim CLM-G0127531
$281.38
billed
$251.47
allowed
$162.00
paid
$34.36
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, new patient | 99204 | $281.38 | $162.00 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, new patient | 99204 | $281.38 | $162.00 |