Claim CLM-G0145212
$409.58
billed
$278.96
allowed
$317.35
paid
$0.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Preventive visit, established patient | 99396 | $242.93 | $204.55 |
| Office visit, established patient, level 4 | 99214 | $166.65 | $112.80 |