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 |
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| Prior Amount Due | $ | 3,389.57 | |
| Less Payment Received | | 3,389.57 | |
| Balance From Prior Billing | | .00 | |
| | | | |
|
CURRENT DUE |
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| 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 | |
| | | | |
|