DATE RECEIVED FILE NUMBER CLAIM NUMBER PATIENT NAME PAYMENT AMOUNT CENTER CLOSE 12/7/2005 21 00022 JACKIE CHAN $201.00 false 8/31/2005 20 00002 GEORGE CLINTON $101.00 false 8/24/2005 19 00011 WILMA FLINTSTONE $300.00 false 8/24/2005 18 00011 WILMA FLINTSTONE $200.00 false 8/23/2005 17 00011 WILMA FLINTSTONE $100.00 false 8/18/2005 16 00005 BILLY BOBB $125.00 false 8/18/2005 15 00005 BILLY BOBB $325.00 false 8/18/2005 14 00005 BILLY BOBB $205.00 false 8/17/2005 12 00005 BILLY BOBB $300.00 false 8/17/2005 11 00005 BILLY BOBB $200.00 false 8/17/2005 13 00005 BILLY BOBB $500.00 false 8/15/2005 9 00007 CLARK KENT $250.00 false 8/15/2005 10 00008 JOHNNY BRAVO $3,109.00 false 8/11/2005 8 00003 JAMES BROWN $500.00 false 5/31/2005 6 00002 GEORGE CLINTON $50.00 false 5/30/2005 7 00002 GEORGE CLINTON $400.00 false 5/30/2005 5 00002 GEORGE CLINTON $100.00 false 6/20/2001 4 00026 BART SIMPSON $330.00 false 6/16/2000 3 00009 FRED FLINTSTONE $1,999.00 false 6/1/2000 1 00002 GEORGE CLINTON $200.00 false

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