Claim CLM-2026501004
$45.31
billed
$31.72
allowed
$0.00
paid
$31.72
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Amoxicillin 500 MG Oral Tablet | 308192 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $40.15 | $28.11 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Amoxicillin 500 MG Oral Tablet | 308192 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $40.15 | $28.11 |