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Selected Claim

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Claim Recap
Selected Claim
Status Finalized Amount Allowed by Plan $37.79
Claim Number 00001585 PPO Discount $41.21
Patient Name DANIEL Amount not payable:
(ineligible amounts)
$0.00
Date of Service(s) 19- Dec-1999 to 19- Dec-1999 Non-Covered Plan Benefits:
(Cosmetic, infertility etc.)
$0.00
Claim Type MEDICAL Deductible $0.00
Total Charges $79.00 Copayment $20.00
Primary Carrier Payment: (COB) $0.00  
 
Payment
Check Number   00045411
Date of Check Mailed 15 -Jan-2000
Payable To: DR. MILLFORD
5555 SUMMIT BLVD., GARDENVILLE
Minnesota 55415
In the Amount of: $17.79
Withhold Amount: $0.00
Patient Owes: $20.00

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