CLAIM NUMBER
00002
PATIENT NAME	PATIENT ADDRESS
GEORGE CLINTON	1 BIMMINY ROAD

                       

CPT CODE	CENTER	DATE	DESCRIPTION	AMOUNT
30890			CATSCAN FEMAR	1125
30890			FEMAR CT SCAN	2000.25
70032			X-RAY FEMAR	1000.75
70032			X-RAY FEMAR	1000.75
70450			CATSCAN HEAD W/O	4045.1
30890			CATSCAN FEMAR	1125
72128			CATSCAN THORACIC	2549.99
30890			CATSCAN FEMAR	1125
20203			CATSCAN SPINAL	3040.5
00000				0
			Total Charges	17012.34
			Total Payments	851
			Balance	16161.34

 

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                            Last modified: January 20, 2010