Claim CLM-2026179002
$38.58
billed
$27.01
allowed
$0.00
paid
$27.01
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Hydrochlorothiazide 25 MG Oral Tablet | 310798 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $38.13 | $26.69 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Hydrochlorothiazide 25 MG Oral Tablet | 310798 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $38.13 | $26.69 |