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Claim Summary Service Line Detail
Claim Detail
Claim  # EMP11223344-1010
Member ID 123456789
Member  Name NANCY PERRIER
Amount Paid ($) 45.00
Service Line Detail
Line # Service Date Service/ Modifier Code Units Charge Amount ($) Amount Paid ($) Dollar Amount ($) Paid Date Check #
Allowed Deductible COIN CoPay
1 03/01/2001 90817 1 48.00 15.00 0.00 0.00 0.00  

 

 

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