EFTA00812178.pdf

Comprehensive Orthopaedic Global STT Foothills Professional Bldg STE 206 St Thomas. VI 00802 Date: 11/28/2018 Time: 3:10:PM:AST Trans Type: Sale! Customer ID: Transaction tr: 66759309 Name: Account: 6512 Ezp Date: Card Type: VISA Entry. Manual AuthCode: 028862 Result: APPROVED Message: AUTH TKT 028862. Description Total Amt: $ 171.02 I Agree to Pay Above Total Amount According to Card Issuer Agreement (Merchant Agreement if Credit Voucher) Signature X !Merchant Copy EFTA00812178  Comprehensive Orthopedk GlobaLPLLC 9151 ESTATE THOMAS SAINT THOMAS, V1.008025165 Tel: 340.779.2663 Fax: 340.779.2443 Receipt of Payment Received Date: 11/28/2018 From HenrikMid Payment ID: 109819 Amount : 171.02 PROMPT PAY Payment CREDI- CARD Type PROMPT PAY CREDIT CARD No: 028862 Charges Details Date Code Desaiption Units Fees Payment 11/28/2018 99213 OFFICE OP LOW COMPLEX 1.00 171.00 -- ---- 68427 LIST CUR MEDS W/DOSAGES DO C BY 11/28/2018 1.00 0.01 PROV 11/28/2018 G8730 PAIN ASSESS POS TOOL F/U PLA NJ DOC 1.00 0.01. 11/28/2018 Patient Payment 171.02 Total 171.02 171.02 Account Balance Summary Total Balance : 0.00 Patient Balance : 0.00 Insurance BalanCe : 0.00 Page I of 2 EFTA00812179