AST END AVENUE New York, NY 10028 Phone 212-860-4800 Date October 21, 2016 I Account ID: 14159 Chart ID: 14159 Coverage Insurance Policy ID Nagnosls: A) N83.202 B) B37.3 SERVICES Date Claim-Line Provider X Ref CPT Units Mod Description Charges Payments Adjusts Balance 10/21/16 63491.1 Dr.