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Annette OFansyan (OGANESOOO0) D 0 8: 06/17/1580 Insured: Self Insurance: Primary Policy: 00010085 10: 364972684 Billing Date Code/CFT Billed Amount Current 31 -60 61-90 91

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Annette OFansyan (OGANESOOO0) D 0 8: 06/17/1580 Insured: Self Insurance: Primary Policy: 00010085 10: 364972684 Billing Date Code/CFT Billed Amount Current 31 -60 61-90 91 -120 120 Total 01/04/20xx 99215/99213 01/13/20xx 95.00 95.00 95.00 66553 01/04/20xx Fat. Co-pay -10.00 -10.00 -10.00 70283 08/09/20xx 99215/99213 05/12/20xx 95.00 95.00 95.00 70283 06/08/20xx Fat. Co-pay -10.00 -10.00 -10.00 Patient Total: 170.00 83.00 0.00 0.00 0.00 83.00 170.00

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