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L`1`IL h0 TALJ --- - I _ 3 AT.ENTCCNTaCLvG 2 <br /> F,Cv bGX 1191 <br /> L L H i L L t N C z 7 51- 5 iEO TAX No 5 S7A'EMEN7 FC c; <br /> ; 7 ccv D; e I o L-R D „:ac 111 <br /> 519—•;66-1?34 04G694' C41994 131 <br /> _%ATIENT NAME 13 PATIENT ACw•c35 <br /> 4 31RTHDATE hS:E.Q 16 MS ^C',4!SciCv .V ?i OHS 2'STAT 2J VEDICAL RECCPC NO I CON ES T -- <br /> 17O 'e�1 3" Pc,23 SPS N <br /> F I Sl 040694 2.33 1 1 1 71 131 C3 <br /> OCCURRENCE _ �� 74 CCCURR^.NC E I ,.•t' ' _.__�. 6 CC%;;F;ENCE SPAN 37 <br /> DATE CODE :A'E ACC =QCU T,R000n /� <br /> r,5 94 11 040694 Al U72976IA2 010494 g <br /> 39 VALUE CODES t, . 41 vAwECCCes <br /> CC DE AM" cooE x r <br /> a V i 46000 <br /> b <br /> c <br /> d <br /> ]^nc^/.CO. 43 DESCR!PPCN 44 HCPCS I RATES 45 SERV.DA c 46 SERV.UNITS 47 TOTAL CHARGES 48 NCN-COVERED 3NARGL: 49 <br /> 110 RGGA—ri:ARD/PVT 475.00 13 617500 <br /> 250 PHARMACY 219 3101742 <br /> 256 IV SOLUTIONS 1 3750 <br /> 270 M ED—SLR SUPPLIES , 24 96000 <br /> 272 STERILIZE SUPPLY 32 257100 <br /> 278 SUPPLYJIMPLANTS 2 315000 <br /> 3GO LASORATORY 32 57000 <br /> 320 DX X—RAY 6 48400 ' <br /> 352 CT SCANYBODY 6 1772-00 <br /> 360 OR SERVICES 1 414500 <br /> 370 AAES7hESIA 2 104000 <br /> 412 INHALATION SVC 3 6800 <br /> 420 PHYSICAL ThERP 4 13700 <br /> 430 OCCUPATION THER 1 300 <br /> 450 EMERG RGOii 1 475CO <br /> I <br /> 710 RECOVERY ROOM 1 31400 <br /> OCI TOTAL CHARGES 2494492 <br /> I <br /> PAYER 51 PROVICER NO. 54 PRICK PAYMENTS 55 EST.AMOUNT DUE 56 - <br /> '4EiMBUR ;LCE N-000C 340061 Y Y <br /> NSURED'S NAME 59 P.REL 60 CERT.-SSN_HIC._ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. <br /> 01 IORANGE COUNTY ATT - CAPT. DILKL <br /> TREATMENT AUTHORIZATION CODES N ESC 6S EMPLOYER NAME 66 EMPLOYER LOCATION <br /> 1 ORANGE CCUNTY JAI <br /> 'ROa DuG.CO. Be CODE 7o CODE <br /> =.Q O CODES I 74 CCCE 78 ADM.DIAG.CO.177 E-COCE 78 .. <br /> 30000 7806 8054 <br /> 190 PRINCIPAL PR00EDURE c, UTnER rROCECURE r.•-tA r4:N l...-:J!_•4'* ;�saY- 82 ATTF-NDING PMY&!D -- <br /> CODE 1 DATE COOE CATF 1 _ <br /> "i 810 a I 7779 104099 0353 " 1040694 C83437 DAHNERS LAURENCE' E <br /> G,rcR PRC;ZouF;E V I r CZL nc OTHER PHYS.!D <br /> COLE DArF 1 1 cOCE I OAr- _ <br /> I o411941 1715 I C; 09S 083437 DAHNERS -sLAURENCE r <br /> _j3 1 C40694 8833 MMARKS OTHER PHYS.10 .• , <br /> da SRC: NThTiVE c6 Gam" ,? a <br /> I <br /> _G <br /> .!CFA-,.•:5C 7 C:R" !7HE CA 17CN5 ON TPE REVERS"PP!Y TOTNIS BILL ANC ARE UAZE A IAR-—_-F_F <br />