cou 9 East 71st Street 1 3/3/201 New York NY 10021 ROM ittan CO up-ORTR/7 . PLEASE CETACS UPPER PORT )N MD RETURN WiTI- YOUR io MITTA *CC TO u. UAL CRC CO TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Perm. 350.00