Claim total
$767.69
base $93.83 · payer covered $617.69
The visit
- Class
- Wellness
- Code
- 162673000
- Reason
- —
- Start
- 2004-01-23
- Stop
- 2004-01-23
The parties
- Patient
- patient Clara Vivien Hackett
- Provider
- provider Brianne Erdman
- Care site
- care site DAKOTA MEDICAL CLINIC, PA
- Payer
- payer Medicaid
Record id
3396e9b6-2bac-15f6-ed2b-da6143b45437