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

CPT CODE	CENTER	DATE	DESCRIPTION	AMOUNT
30890			CATSCAN FEMAR	$1,125.00
30890			FEMAR CT SCAN	$2,000.25
70032			X-RAY FEMAR	$1,000.75
70032			X-RAY FEMAR	$1,000.75
70450			CATSCAN HEAD W/O	$4,045.10
30890			CATSCAN FEMAR	$1,125.00
72128			CATSCAN THORACIC	$2,549.99
30890			CATSCAN FEMAR	$1,125.00
20203			CATSCAN SPINAL	$3,040.50
00000				$0.00
			Total Charges	$17,012.34
			Total Payments	$851.00
			Balance	$16,161.34

                                                                            

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