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OATS 03/20/92 PROVIDER VOUe..cR lISTINS PACE i
tP0003?
FOR PROVIDER: 74-2078288 ANESTNESIA ASSOCIATES
FOR TPR-OOT~ IQ:RR COUNTY
SEQUENCE N0: 1
PATIENT CLAIM It~RfD COtlERE1 TOTAL
CLAIMANT DEP. N0. N0. FROM TO CMAitCE PAID
xsxas:aasssaas~sax:sssaaasesaaassssssassssssaassasaxasaasxasas:sss:sas:assxsxssss::x
J CARCES E 003024 9200013407 01/2i/92 01/21/92 7b0.00 358.80
CROUP TOTAL: 760.OD 336.80
PROVIDER TOTAL: 76tl.00 338.80

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--_ _ . _ _ ~'.A. _... -- -
DA ~ Q4/10/9Z PRO1fIDER UOIICHER LISTING PACE t
tPV0431
F~ PR0IIDER: 7f-Z2~3887 PRIOUR M0, N L
FOR CRO1~: TPX-OOZ4 KERB COlMTY
SE~IEMCE N0: 1
PATIENT CLAIfI INCIMtRFD COVERED TOTA!
CLAIMANT DEP. N0. M0. FROM TO CHARGE PAID
atssss:ssaesszssess~ses:sass=-sasca=saasxarssasxxsassa-_asassnsss:s~sssa:a=xsazssass
D MARSHALL E 920002b507 12/19!91 12119/91 1150.00 1014.Oi
GROID' TOTAL : i t 30.00 1014.01
----_-. ` _-- _ ~_ _ PR04IDER TOTAL:_ _ll~tt.OQ.. _10]9,9].
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UnTF; ',J4/~!319'i D A I L Y C M S C K t u 1 5 l t k B Y b ~ U U p P46E: 9
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CHECK CHECK
NUM6Ek DATE CLAIM NU SUC SEC NU EMPLUYtE
.,__.. ..___.._.._ ____'___. _.
ruNU: iPX-0014 GRUGP: TPx-UU24 iiEKr. CUU~iTY	CNECK
CL AIY4NT PAY TO AMOUNT
. _.. -..__ _ca..-,.._.._..___..__._.sc.ar.cGr.e:::cx:.cc=cxa=csc-=-a=ccct eeaaass~s pcessd
lb7b 04/03/Y2	MANaL OTHEk VOID .00
167fi U4/C:i/92	VOUCr_K PAYMENT KILL CUUNTf?Y kAJIULCGY 53.76
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JATF 49!43/97 PROVIDEk ,JCNER LISTIhs PR6f 1
iPV4431
FOR PRDUIDER~ 79-1733161 HILL COUNTRY RADIOLOGY
FOfi GROUP: TPR-0429 !;ERR COUNTY
SEQUENCE N0: 1
PATIENT CLAIif INCURRED COVERED TOTAL
CLAIriANT DEP. N0. NO. FROiI TO CHARGE PAID
- ---- ------ -
R ROYBAL E 133777 9200029548 12!19!91 12!19/91 105.OG 53.16
GROUP TOTAL 105.00 53.7b
__ _ _ _ _ PROVIDER TOTAL: 105.OD _ 53.76