Claim CLM-2026002000
$61.15
billed
$42.80
allowed
$0.00
paid
$42.80
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Acetaminophen 21.7 MG/ML / Dextromethorphan Hydrobromide 1 MG/ML / doxylamine succinate 0.417 MG/ML Oral Solution | 1043400 | $0.00 | $0.00 |