EFTA02724411

SEP-7-2011 11:138 FROM:DR TI-CMS MAGIANI 2123979008 T0:16467067223 P.1'1 t Thome Magnani D.0.8. Alvin on D.D.S. stein th Street Date 6/3/2011 6/3/2011 6/3/2011 6/3/2011 6/6/2011 6/6/2011 6/6/2011 6/21/2011 6/21/2011 Current Is De Corr prehensive Adult Scale & Pr Pantmic Film Bite ings 4 Fil AmOgam 1 Surf Amalgam 2 Surf Am4gam 2 Surf Amalgam 2 Surf Amalgam 2 Surf AN1 Grayson D.D.S notion al eval by Perrn, Perm. Perm, Perm, Perm, 7 West 51st Street HISTORICAL STATEMENT 1/1/2011 to 9/7/201 Telepho Date Account 9824 9/7/2011 Charges 60.00 180.00 150.00 50.00 275.00 375.00 375.00 375.00 375.00 Credits I Balance 60.00 240.00 390.00 440.00 715.00 1,090.00 1,465.00 1,840.00 2,215.00 Account Total 2,215.00 Patient Charges 2,215.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 90 Days 120+ Days New York NY 10019 (212) 688-1090 EFTA_R1_02211240 EFTA02724411