Claim total
$1,397.10
base $93.83 · payer covered $1,397.10
The visit
- Class
- Wellness
- Code
- 162673000
- Reason
- —
- Start
- 2024-06-22
- Stop
- 2024-06-22
The parties
- Patient
- patient Rafael Jacob Stark
- Provider
- provider Roslyn Reichel
- Care site
- care site SOUTHSIDE COMMUNITY CLINIC
- Payer
- payer Dual Eligible
Record id
317ac6ea-e6de-31fb-89fc-77dd1a422115