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FIRST LAST L 00012312312 06/66/66 S 23 PPPPZ(777)777-7777 77/77/77
500 E 895TH ST LARAMIE WY 82700 04 01 636-6610
125251235
NOTE #1.. NOTE #2..
NOTE #3.. NOTE #4..
SERVICE POSTING ST DR T TC CPT DESCRIPTION INS FILED AMOUNTS BALANCE
1 05/28/10 06/09/10 04 22 E 01 11111 AB ABCDEFHIJK BLAB EXT CONTRAST 222.33 246.92
2 05/28/10 06/09/10 04 23 E 01 111111 LT SHOULDER COMP MIN 2-V 42.67 289.59
3 08/31/10 08/31/10 04 22 E 01 263 AB ABCDEFHIJK BLAB EXT DBA 289.59 0.00
OP DATE TP COMMENT
CM 07/15/10 O AB ABCDEFHIJK BLAB EXT AB ABCDEFHIJK BLAB EXT T-19
CM 07/15/10 O AB ABCDEFHIJK BLAB EXT AB ABCDEFHIJK BLAB EXT CM 07/15/10 O CALL
CM 07/15/10 O AB ABCDEFHIJK BLAB EXT AB ABCDEFHIJK BLAB EXT CM 07/15/10 O IS DIFF
S5 07/19/10 O AB ABCDEFHIJK BLAB EXT
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