Please do not use or disclose the information contained here for any purposes other than ones permitted under HIPAA.\ Back Print\ File Ref. Number: 206113043799\ Provider Control Number:\ Status: PROCESSED on 06/12/2012\ Claim Source: CPS\ Claim Year: 2012\ Rendered by: DR. BEKKI PATTON\ Location of Service: OFFICE\ Patient Name: XFXUXSPXKER\ Relationship to Subscriber: Self\ Subscriber Name: XRXXSPNXXXXX\ SSN or Identification Number: XXXXX2CE\ Group Number: 120731\ Provider ID: XXXXX6255\ \\\\table[[\\\\table[[Date of],[Service]],\\\\table[[Service],[Description],[(Code)]],\\\\table[[Tooth#],[/Area]],\\\\table[[Fee],[Charged]],\\\\table[[PDP Fee],[(if],[applicable)]],\\\\table[[Covered],[Expense]],\\\\table[[Deductible],[Applied]],\\\\table[[Plan],[Benefit]],Notes],[

(04)/(30)/2012

,\\\\table[[LMITED ORAL],[EVALUATION],[(D0140)]],,

$60.00

,

$35.00

,

$35.00

,,

$35.00

,

J

Please do not use or disclose the information contained here for any purposes other than ones permitted under HIPAA. Back Pri As of 06/12/2012,$359.00 has been applied toward the plan maximum of $10,000.00. Please print and save for your tax purposes. This is the only statement to be issued. Note: This claim detail does not replace the printed Explanation of Benefits the patient will receive in the mail. Additional Notes Benefits are calculated in accordance with the coordination of benefits provision. 3 : THE DENTAL BENEFIT FOR THIS SERVICE TAKES INTO CONSIDERATION ANY PAYMENT OR NON