Claim CLM-2026501007
$347.47
billed
$243.23
allowed
$0.00
paid
$243.23
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Ibuprofen 100 MG Oral Tablet | 198405 | $0.00 | $0.00 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Ibuprofen 100 MG Oral Tablet | 198405 | $0.00 | $0.00 |