Claim CLM-G0128204
$484.47
billed
$432.75
allowed
$334.43
paid
$26.04
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Telehealth visit, level 3 | 99213 | $100.26 | $48.03 |
| Office visit, new patient | 99204 | $282.11 | $215.62 |
| Chest radiograph, 2 views | 71046 | $102.10 | $70.78 |