Claim CLM-2026634002
$5,263.67
billed
$4,711.40
allowed
$4,096.87
paid
$614.53
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Outpatient procedure (procedure) | 371883000 | $0.00 | $0.00 |
| Subcutaneous immunotherapy (procedure) | 180256009 | $5,121.09 | $3,584.76 |