A123456789    DOE, JANE                                                         08/10/16     319.25   23.00                    54.27                                         CLMPD         Claim paid correctly per        08/15/17                                      BAR.ID   HMO    
A123456789    DOE, JANE                                                         08/10/16              23.00                    54.27                                         CLMPD                                                              08/15/17                                      BAR.ID   HMO    
A123456789    DOE, JANE                                                         08/10/16     319.25                            54.27                                         CLMPD         Contract Calculation-           08/15/17                                      BAR.ID