EFTA00772494.pdf

JUN-24-2009 09:17A FROM:DR THOMAS MAGNANI TO: P.1/1 HISTORICAL STATEMENT 4/1/2009 to 6/24/2009 [Andra Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein Dale Act.vimit Jeff Epstein 6/24/2009 9118 Nyc NY 10019 Date Patient Description Charges Credits Balance 4/21/2009 Andra Comprehensive Oral oval 50.00 50.00 4/21/2009 Andra FMS with Bite wings 175.00 225.00 4/21/2009 Andra Bite Wings 4 Films 65.00 290.00 4/21/2009 Andra Adult Scale & Prophy 160.00 460.00 4/21/2009 Andra Fluorid 12.00 462.00 4/22/2009 Andra AMERICAN EXPRESS 462.00 0.00 4/29/2009 Andra 1 Periaplcal X Ray 25 fX) 25 00 4/29/2009 Andra Amalgam 4+ Surface Perm. 425.00 450.00 4/29/2009 Andra Amalgam 4+ Surface Perm. 425.00 875.00 5/7/2009 Andra Amalgam 3 Surface Perm. 375.00 1,250.00 5/11/2009 Andra Amalgam 3 Surface Perm. 375.00 1,625.00 5/11/2009 Andra Comp. W. Etch 2 Surface 325.00 1,950.00 5/11/2009 Andra Comp. W. Etch 2 Surface 325.00 2,275.00 5/11/2009 Andra Comp. W. Etch 2 Surface 325.00 2,600.00 5/19/2009 Andra Porcelain W. Gold Crown 1,800.00 4.400 00 5/27/2009 Andra Amalgam 1 Surface Perm. 275.00 4,675.00 5/27/2009 Andra Amalgam 1 Surface Perm. 275.00 4,950.00 5/27/2009 Andra Amalgam 1 Surface Perm. 275.00 5,225.00 5/28/2009 Andra Temporary Cement 0.00 5,225.00 Account Total 5,225.00 Patient Charges 5,687.00 Patient Payments 462.00- Patient Credits 0.00 Patient Debits 0.00 Current 30 Days 60 Days 90 Days 120+ Days Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA00772494