Claim CLM-2026002002
$352.50
billed
$198.44
allowed
$172.56
paid
$25.88
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Well child visit (procedure) | 410620009 | $0.00 | $0.00 |
| Medication reconciliation (procedure) | 430193006 | $215.70 | $150.99 |