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Claim Summary Service Line Detail
Claim Detail
Claim  # EMP0758197
Member ID 123456789
Member  Name PERRIER , NANCY
Provider  Name TUMNUS , PETER
Charge Amount ($) 48.00
Paid Amount ($) 15.00

 

Service Lines
Line # Service Date Type of Service Procedure Code Charge Amount ($) Allowed Amount($) Paid Amount ($)
1 02/23/2001 MI 90817 48.00 15.00
 

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