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Selected Claim

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Claim Recap
Selected Claim
Status Finalized Amount Allowed by Plan $0.00
Claim Number 30075802-01 PPO Discount $187.00
Patient Name TIFFANY Amount not payable:
(ineligible amounts)
$0.00
Date of Service(s) 03 Feb 2003 to 03 Feb 2003 Non-Covered Plan Benefits:
(Cosmetic, infertility etc.)
$0.00
Claim Type MEDICAL Deductible $133.00
Total Charges $320.00 Copayment $0.00
Primary Carrier Payment: (COB) $0.00  
 
Payment
Check Number  
Date of Check Mailed  
Payable To: Not Available
In the Amount of: $0.00
Withhold Amount: $0.00
Patient Owes: $133.00

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