Ukl)rFt ha t7. `1b1c_ CL_Fi I h15 (ii~iD FiGCC ~hi'ul t~ tJr-~ thzs the ~"lth day of J~_tly 1°~~_j,:3, game orr to be cansider,ed i..-~y the vario~_rs C1<TOR t P A IkC DATF 47/02/93 PFOUIDFR UOUCHFR LISII!!6 PAGE t tPL'003) tOR PROVIDER: 14-1611142 SOUTM TFXA5 RADIOLOSY GR FOR 6ROUP~ TPk-4024 kFiRT~ ~D~II`ISTR4~fOR T. P. A., INC. GATE 01/02/93 PRQVIDER VOUCHER LISTING PAGE f ipV003} fOfi PROVIDER 14-24523b7 AlAHO PHYSICIANS SERVICE fOR GROUP: TPX-0024 KERR COUNTY SEQUENCE MDR 8 PATIENT CLAIM INCURRED COVERED TOTAL CLAMANT DEP. N0. N0. fR011 TO GNAR6E PAID J COLEMAN E 002089ib 93042b290i 03/22!43 03/22/93 ib0.00 b9.60 J LORREY E 00211818 9300412422 04/22/93 05/11/43 500.00 86.53 B SHIPMAN E 002142b3 9300262601 04/13/93 04/16!93 11 b. 00 10.40 GROUP TOTAL: 77b.40 22b.53 PROVIDER TOTAL: 776.00 ?2b.53 __ _.. nw ~f]A \N Om~ ~Ry-Ron [nc. THIRD PaRTI 4Dti11ti1STRATOR '. P. A., INC. -ATE 07/02/93 PROVIDER VOUCHER LISTING PAGE 1 tPU003) FUR PROVIDER: 74-2557820 SID PETERSON MEM HOSPITAL FOR CROUP: IPR-0024 KERR COUNTY SEQUENCE N0: 9 PATIENT CLAIM INCUtRED COVERFD TOTAL CLAIMANT DE P. 1l0. M0. FROM TO CHARGE PAID :======ceseaaa.. ,c.e. xasese=eas.n ..eeeoeee.oe..a-..ac...e...ec..: ==ecc....c. x...=:~_= T CERSTENBER6 E 200336 9300262803 02!01/93 02/04/93 3170.80 3009.26 J MOLINA E 5581$2 9300260102 05/22!93 05/22/93 106.25 106.25 A ROPBAL E 243110 9300112205 05/08/93 05/17/93 9302.90 5407.09 J SCHUPP E 9300263301 03/21/93 43/23/93 2318.00 466.32 B SNIPMAN E 345492 9300262603 04/13!93 05/05/93 72?.65 624.35 B SHIPMAN E 145492 9300262605 04/21193 Od/21/93 376.20 308.49 CROUP TOTAL 15997.80 9921.16 PRWIDER TOTAL: 15997.8D 9921.16 COMPANY ®m _ . Ry~-Ron lnc. ~~~ I BIRD PaRTI ~~D~ll\ISTR4F'OR i P. A., INC. DATE 07/02/93 PROVIDER VOUCHER LISTING PAGE 1 tPU003) FOR PROVIDER: 74-2113931 UINAS HD, JOSEPH F FOR CROUP: iPR-0024 KERB C011NTY SEQUENCE N0: 10 PATIENT CLAIM INCURRED COUERE9 TOTflI C1AINflNT DEP. NO. N0. FROM 10 C8AR6E PAID R NATCNETT E 4300262702 05/17/93 05/17/43 260.00 87.34 CROUP TOTAL: 260.00 $7.34 PRO+IDER TOTAL: 260.00 87.34 COMPANY ~(~~ Ry-Ron Inc. THIRD PaRTl aD~11~ISTRATOR i. P. A., IMC. DATE 07/02/93 PROVIDER UOllCHER LISTIM6 PACE 1 (P00031 FOR PROVIDER: 14-17383)0 DELAHEY AD, R 60RDON FOR CROUP: TPX-0024 KfRR COU1fiY SEQUEl~E 110: tt PATIEi1T CLAIM IMCIIRRED COUERE! TOTAL CLAIIIAKT DEP. N0. N0. FRON TO pIARCE PAID ===----==---=====-====-=~=_=-==== =_===-===-=_==-=-=-===_=====s=== ==--==_=-==-=_=_===_ l MORRIS E 0014b943 9300260203 05Jt0/93 0511)193 1155.00 426.51 L l10RRIS F OOtOb943 9300260206 05/18/93 05/18/93 2075.00 500.24 CR'1NlP iOTAI : 3230.00 926. )S PRWIDER TOTALS 3230.OQ 926.15 ®~ __..y-Flo~~ inc. __ THIRD PaRTI aD~11~ItiTRATOR T. P. A., INC. DRTE 07/02/43 PROVIDER UOUCHFR LISTIM6 PAGE ; (PU043t FOR PROVIDER: 59-1370018E JACK FCKERD COR FOR CROUP T~P%-0024 KERR COUNTY SEQUEIICE k0: 12 PATIEi1T CLAIM I1ICURRED COUEREH TOTAL CLAIIIAltT OEP. N0. M0. FROM TO CHARGE PAID D DAMZ E 0]5544 93000b1220 05/01!93 05!10/93 115.99 115.99 S LAt1E F 08125b 9304202507 04/23/93 05/17/93 151.bb 144.52 6ROlIP TOTAt: 267.b5 2b0.51 PROVIDER TOTAL: 261.b5 260.5t rneepeniv ®mL Ry-Ron lnc. THIRD P~RT~ aD~ll`ISTRATOR T. P. A., ItlC. DATE 41/01/93 PROUIDFR UOUCHFR IISTIM6 PACE t 1P0003? FOR PROVIDER: 14-2114159 tIERRITT lfD, EARL FOR CROUP: TPX-0424 KERB COUNTY SEQUENCE NO: f 3 PATIEiIT CLAIM IlICllRRED COVERER TOTAI CLAIdAMT OEP. N0. N0. FROM TO CIMRCE PAID =x.seaa~::==eoec=c=c=oe¢s=~===o.nce...~_~_=...az:.ss...ce.s3e=aoc.aaces..z~asa=e.acax R HATCMETT E 93002b2701 05/17/93 05/17/93 1300.00 54b.33 CROUP TOTRI~ 1300.QO 546.13 PROVIDER TOTAL: 1300.40 546.33 GQMPANY ~®~ Ry-Ron Inc. THIRD PART} 1D}lltil'. DATE 01142/93 FOR PRQVIDER: 14-26213b6 F~ GROUP: TPX-0029 SEQUENCE N0: 19 ~TR4TOR T. P. A., INC. PROVIDER UOUCHFR LISTING PAGE tPU0031 BOONE MD, DAM KERB COUttTY PATIENT CLAIM iNCUR'RED COUERE! TOTAL CLAIMANT DEP. lOy. N0. fROM TO CNARCE PAID T 6ER5TENBER6 E 93002b2801 05/21/93 05/27/43 26.01 2b.01 CROUP TOTAL: 2b.01 26.01 PROVIDER TOTAL: 26.01 2b.01 __ ___ ~n~tpannr ®m~ Ry-Ron Inc. rH~RU r~aNTl ao~ii~is~rNarott [. P. A., INC. DATE 07/02/93 PROVIDER VOUCHER LISTIM6 PAGE 1 (P0003) fOR PROVIDER: 74-2311724 MITCHFII IID, ROBERT F fOR &RWP: TPX-0024 NERR COUHTV SEQUEIfCf kO: 15 PATIENT CLAIM INCURRED COUEREI iOTAI GLAIlIAMT DEP. H0. i10. FRO!! TO CHAR6f PAID U 02UMA F 5972 9304186806 05/13/93 06101/93 610.85 247.50 CROUP T4TAL~ 610.85 141.50 PROVIDER TOTALS 6i 0.85 247.50 _- r+rv.ne~o. ~; .~ J ~, w \.1 °' II III~II ppuu 11~'I~H 1 i1 l111f16 ~~~4 NNHN ~ --~ ----...__ _ ..~.. _ ._ - ~HNH NNhk ~HHR OE LI SN~3N~ f SlVi01Af15 ++ lb'G 0 S3NVf 'OW Sll3M 1N3WAVd tl3H~lIOA bB00-Xdl f6/60/LO FIZZ 6d L ' 39N3I~S OI8 3NIlNH1[WS 1N3NAVd tl3N0110A bZ00-Xdl E6/60lLO bICZ 00 ++ k ~ 3 H 9 O I O A ++ dfl 3NIl f6160lLO EI~Z 00 OIOA N3N10 lVf1NVW b200-Xdl f6/fi0/LO 2lZ@ ALNf10~ Md3M b20 d(lO d'J NJ3H~ yyu uu ~ Q II xa_xxxaxx A asaxsx assseaama:esmasaaseasst: maccaxsxxa:aesess asezzassseasaoemmcmaacemamoauss aaemmo emam sea^•saaa xaszaxccsox xzxnccaszs 1fuNu ~IyNM 1Nfl~)WV O1 Atld 1NVNIVIa 33AOldW3 ON X39 30S ON df10tl9 ON W1Vl~ 31V0 d38Wf1N , N73H7 H93N9 NJ3HJ f8Z tl3BWf1N tl31SI~3tl '? E661 '6 Alflf AVOltl3 L 39Vd tl 3 1 S 1 9 3 tl N J 3 H 9 A l i V 0 Lfi/60/10 ~3LV0 ~NI V d'1 ') ®m® ~-Ron lnc. rEiiK~~ P~Rl1 1D~11\Iti1RaTOR I. P. A., IlIC. DATE 07/09/93 PROVIDER UOUCNER LISTING PAGE 1 iPU0031 FOR PROVIDER: 14-2128108A SMITHKLIME BIO SCIE?ICF FOR CROUP: TPR-0024 HERB COUi1T9 SEQUENCE H0: 7 PATIEilT CLAIM INCURRED COUERF9 TOTAL CLAIMAi11 DFP. M0. M0. FROM TO CHARGE PAID D SANCNFZ E 11677 9300060919 12/23/9? 12/23/92 16.00 ).89 CROUP TOTAI: 16.00 7.89 PROVIDER TOTAL: 1b.00 7.89 -®~ Ry~-Ron Inc. fHIRD P~RT1 1D~11\I DATE 07/09/93 FOR PROVIDER: 74-1918693 FOR CROUP: TPX-0024 SEQUEIN:E !!0: 8 ~TRaTOR T. P. A., INC. PROVIDER VOUCHER LISTING PACE 1 iPUO03l BELLS MD, JAMES D KERR COUNTY PATIFNT CLAIM INClNt1iFD COUEREI TOTAL CLAIMANT DEP. NO. M0. FROA TO CHARGE PAID J LOHRE4 F IOHERJOO 9300012024 05!11/93 OS/it/93 21.00 9.41 CROtP TOTAL: Zi.OO 4.4i PROVIDER TOTAL: T1.O0 9.41