| Invoice Number: | 140979 |
| Billing Period: | 01/01/2007 - 01/31/2007 |
| Dental Group Number: | 03905-000-00005-00000 |
| Vision Group Number: | 40013-000-00000-00000 |
| Group Name: | FULLY INSURED JOINT-BILLED |
| Master Number: | 10302 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| FULLY INSURED JOINT-BILLED |
| JANE SINCLAIR |
| 500 DIAMOND AVENUE |
| ANYWHERE, USA 55555-0000 |
| PRIOR DUE |
|---|
| | Prior Amount Due | $ | 3,389.57 | |
| | Less Payment Received | | 3,389.57 | |
| | Balance From Prior Billing | | .00 | |
| | | | | |
| |
| CURRENT DUE |
|---|
| | Dental Total Subscriber Adjustments | $ | 42.84 | |
| | Vision Total Subscriber Adjustments | | 3.01 | |
| | Total Total Subscriber Adjustments | $ | 45.85 | |
| | | | | |
| | Dental Current Billed | | 3,076.42 | |
| | Vision Current Billed | | 257.53 | |
| | Total Current Billed | $ | 3,333.95 | |
| | | | | |
| |
| | Total Amount Due | $ | 3,333.95 | |
| | | | | |
| |
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