Claim CLM-2026088001
$10,184.12
billed
$9,238.22
allowed
$8,033.23
paid
$1,204.99
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Prenatal visit (regime/therapy) | 424619006 | $0.00 | $0.00 |
| Hemogram, automated, with red blood cells, white blood cells, hemoglobin, hematocrit, indices, platelet count, and manual white blood cell differential (procedure) | 104091002 | $862.80 | $603.96 |
| Administration of vaccine product containing only Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae antigens (procedure) | 399014008 | $1,108.27 | $775.79 |
| Urine screening for glucose (procedure) | 268556000 | $1,955.75 | $1,369.02 |