Claim CLM-2026501003
$347.38
billed
$193.73
allowed
$168.46
paid
$25.27
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Well child visit (procedure) | 410620009 | $0.00 | $0.00 |
| Influenza, split virus, trivalent, PF | 140 | $136.00 | $95.20 |
| CBC panel - Blood by Automated count | 58410-2 | $74.58 | $52.21 |