MRY-12-2011 09:50A FROM: CR THOMAS MAGNRNI

MRY-12-2011 09:50A FROM: CR THOMAS MAGNRNI i I Thom4 Alvin GI 7 West:5 7th Flobr, New Yti Magnani D.D.$ son D.D.S. t Street Y 10019 Mr. Jett stein 301 East th Street Apt 10p , New Y,0r NY 10065 Date , 11/22/2010 11/22/2010 11/22/2010 12/13/2010 12/13/2010 12/14/2010 12/14/2010 12/17/2010 12/20/2010 1/7/2011, 1/7/2011 1/14/2011 1/21/2011 1/25/2011 2/10/2011 3/2/2011. 4/21/2011 4/21/2011 4/21/2011 2123979008 lit TO:16467067223 P.1/2 tea_ HISTORICAL STATEMENT 11/22/2010 to 4/30/2011 Telephone: (212) 686-1090 Dale Account 5/12/2011 9648 0 ription Charges Credits Balance FM Am Am Co Cor Co Previc with Bite wi Igam 1 Surf. Igam 3 Surf p. W. Etch p. W. Etch prehensive Ad I Scale & Pr MASTER CARD Por4elain W. Go Epoateal 'avian Epoeteal Implant Office Visit MA TER CARD Po elain W. Go Crown • 1 P riapical X R Am Igam 2 Surf Pert. Abi ment Place nt 1 , Abutment Place nt i l Por4elain W. Go Crown: I Balance Bs e Pennl. e Pemt Surface) Surface' ral eval hy Crown: 175.00 325.00 375.00 275.00 275.00 50.00 160.00 1,850.00 2,300.00 2,300.00 0.00 1,850.00 25.00 375.00 925.00 925.00 1,900.00 1,425 00 1,850 00 0.00 175.00 500.00 875.00 1,150.00 1,425.00 1,475.00 1,835.00 210.00 2,060.00 4,360.00 6,660.00 6,660.00 4,810.00 6,660.00 6,685.00 7,060.00 7,985.00 8,910.00 10,810.00 Page 1 Thoma onant0.0.5 I 6015ps Aisle Grayson D.D.S4 7 Mat 51st Snot( Continued 120+ Days New Yore NY 10019 (212)688.1090 EFTA01107466 MAY-12-2011 09:51A FROM: CR THOMAS HAGNANI 2123979008 1 II TO:16467067223 P.2'2 Thonlia, Alvin qr 7 West 5 7th Flop New ycir, , NY 10019 Mr. Jeff stein 301 Elf th Street Apt 10 New Yti NY 10065 Magnanl D.D.S. son D.D.S. t Street HISTORICAL STATEMENT 11/22/2010 to 4/30/2011 Telephone: (212) 688-1090 Date Account 5/12/2011 9648 Date . P ient D option - li Charges Credits Balance 4/21/2011 t i t I Por elain W. Go Crown. 1 Ef i Ii E I 1,900.00 12,710.00 Page 2 i I Account Total 12,710.00 Patient Charges 15,986.00 I Patient Payments 3,275.00- Patient Credits 0.00 Patient Debits 0.00 Current 30 Days 60 Days 1 90 Days 120+ Days Thomatst,I. nani D.D S ANIGtayson D.D S 7 West Slat Stroot Fle I New York NY 10019 (212)888.1090 EFTA01107467