Claim CLM-G0148307
$503.11
billed
$415.26
allowed
$301.61
paid
$28.88
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 4 | 99214 | $184.63 | $109.99 |
| Office visit, new patient | 99204 | $318.48 | $191.62 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Office visit, established patient, level 4 | 99214 | $184.63 | $109.99 |
| Office visit, new patient | 99204 | $318.48 | $191.62 |