02/11/2016 13:34

02/11/2016 13:34 2123155160 NUSIKANT DEUTSCH PC PAGE 01/02 PRACTICE LIMITED TO ENDODCVTIC3 STEVEN D KAPLAN, D.M.D. ALEN JiAK0B, D.M.D. PRACTICE LimIrmo To ENOODONTICS P. 212 - 245-1066 C. 917 - 576-2698 FAX CO 119W8ST57STREET SUITE 700 NEW YORK. N.Y. 10019 ER LETTER Date: IL Lk c;- To: 2 ( it i From: ;( k :-,(eiLJ“ ---31 ../ .i, Number Of Pages Including This Cover Sheet cr:› Comments: 1--s.\!;._ 17- #(17--, CCOICLALVZ-51C .-11C-P,r1/4.1-et/t. OtfrCW, cei,.4 a I 24.413.10368 FAX Q12-316-6160 DNS EFTA01185864 02/11/2016 13:34 2123155160 MUSIKANT DEUTSCH PC PATIENT Strkatti wsteast PACE 02/02 Steven D Kaplan, DMD 119 West 57th Street Suite 700 New York NY 10019 (212) 245-1066 DATE 02/11/2016 ACCOUNT NO. 9617-0 MC PATIENT DESCRIPTION CHARGE CREDIT EXPECTED INS PATIENT CHARGE C2/11/2016 Ret reatatent -molar ADA: D3348 Tooth: Steven D. Kaplan LIC. 034161 19 Tax 25C.0.3C ID. 133161736 .00 2500.00 SUIVAIARY INSURANCE PATIENT ADDITIONAL INFORmATIONAPPOINTNENT SCHEDULING PREVIOUS ACCOUNT BALANCE .00 .00 CHARGES FOR TODAY'S VISIT .00 + 2500.00 PAYMENT .00 CURRENTACCOUNT BALANCE .00 2500.00 TOTAL OBLIGATION 2 500.00 PLEASE PAY THIS AMOUNT --> 2500.00 If your insurance company pays more than expected, you win be credied the difference. II your insurance company pays less than eVected, you will be charged the difference. Friel nasponsibdity for payment rests with the person to whom this receipt is addressed. EFTA01185865