YABLE / REMIT TO: $55.00 1023)$ . 112 STATEMENT 26-3354934 CARDIOVASCULAR INSTITUTE OF MO P.O. BOX 28083 NEW YORK NY 10087-8083 PLEASE DETACH MD RETLAN OP PORTION MTH YOUll PAYMENT IN ENCI OSLO EliVELOFE DATE OF SERVICE • DESCRIPTION OF SERVICE AMOUNT 1 0/24/13 1 AD 110122266 900.00 10/24/13 1 09967 PHA