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Claim Summary Service Line Detail
Claim Detail
Claim  # 01- 061407- 4069- 99998
Member ID 123456789
Member  Name PERRIER , NANCY
Provider  Name TUMNUS , PETER
Charge Amount ($) 385.00
Paid Amount ($) 200.00

 

Service Lines
Line # Service Dates Type of Service Procedure Code Charge Amount ($)
1 03/01/2001 03/01/2001 00104 385.00

 

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