Claim CLM-2026173002
$31.73
billed
$22.21
allowed
$0.00
paid
$22.21
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet | 860975 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $31.01 | $21.71 |