Claim CLM-2026185007
$989.36
billed
$2,509.13
allowed
$2,509.13
paid
$0.00
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| General examination of patient (procedure) | 162673000 | $0.00 | $0.00 |
| zoster vaccine, live | 121 | $136.00 | $0.00 |
| Influenza, split virus, trivalent, PF | 140 | $136.00 | $0.00 |
| Basic metabolic panel - Blood | 51990-0 | $74.58 | $0.00 |