Claim CLM-2026185006
$46.15
billed
$32.31
allowed
$0.00
paid
$32.31
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 | $40.01 | $28.01 |