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William Tsosie MRN-204175 · born 2015-01-23 ✦ AI Ask ✦ AI Ambient note Chart

Claim CLM-G0104598

William Tsosie MRN-204175 Payer Medicaid Service Oct 7, 2025 Status paid
$119.35
billed
$72.58
allowed
$96.92
paid
$0.00
patient responsibility

Adjudication lines

ServiceCodeBilled Paid
Office visit, established patient, level 399213 $119.35 $96.92