: 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. Karen KIRSCH A,B 99212 1 Subseq. visit focused 175.00 0.00 Pad 10/21/16 Paid On: 10/21/16 Patient Payment - Cr 175.00 10/21/16 63491.2 Dr. Karen KIRSCH

er 18, 2016 Account ID: 14159 Chart ID: 14159 Coverage Insurance Policy ID Date Claim-Line Provider X Ref CPT Units Mod 10/18/16 63450-1 Dr. Karen KIRSCH &WC 99213 1 10/18/16 Paid On. 10/18116 10/18/16 81159.2 Dr. Karen KIRSCH A 90636 1 10/18/16 Paid On 10/18/16 10/18/16 63459.3 Dr. Karen KIR