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Sani Dean Todacheene MRN-212235 · born 1981-11-16 ✦ AI Ask ✦ AI Ambient note Chart

Claim CLM-G0117166

Sani Dean Todacheene MRN-212235 Payer Blue Cross Blue Shield Service Jun 15, 2026 Status paid
$331.14
billed
$217.72
allowed
$191.01
paid
$4.10
patient responsibility

Adjudication lines

ServiceCodeBilled Paid
Office visit, established patient, level 399213 $162.84 $73.34
Office visit, established patient, level 499214 $168.30 $117.67