Claim CLM-2026173005
$866.52
billed
$2,464.74
allowed
$2,143.25
paid
$321.49
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| General examination of patient (procedure) | 162673000 | $0.00 | $0.00 |
| Medication review due (situation) | 314529007 | $0.00 | $0.00 |
| Basic metabolic 2000 panel - Serum or Plasma | 24321-2 | $74.58 | $52.21 |
| Urinalysis macro (dipstick) panel - Urine | 24357-6 | $74.58 | $52.21 |