.11 Notes* Your Plan Paid (s $27.58 $27.81 $9.85 $0.00 $2.93 $5.42 $73.39 Patient Account Number 156189349 e•.ucGDl• r-. Your lionized Res nsl • C••ay . to Provider • " a *0.00 $6.89 $0.00 . $0.00 $0.00 $8.95 $0.00 $8 $0.00 $0.00 52.41 $0.00 $2.41 $0.00 $0 .00 $0.00 $49