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Claim Summary Service Line Detail
Claim Detail
Claim  # EMP11223344-1010
Member ID xxxxx4321
Member  Name PERRIER , NANCY
Provider  Name TUMNUS , PETER
Charge Amount ($) 144.00
Paid Amount ($) 45.00

 

Service Lines
Line # Service Date Type of Service Procedure Code Charge Amount ($) Allowed Amount($) Paid Amount ($)
1 03/01/2001 MI 90817 48.00 15.00
 

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