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<br />.. <br /> <br />F A I R V I E W SOU T H D ALE HaS PIT 3 PATIENT CONTROL NUMBER <br />PO BOX 147 <br />MINNEAPOLIS MN <br />(612)672-2762 <br />10 PATIENT'S LAST NAME <br /> <br /> <br />!:JYLLIS A STRONG <br />EDINBOROUGH WAY 3105 <br /> <br />34 <br /> <br />EDINA MN 55435-5609 <br /> <br />FIRST NAME <br /> <br />INITIAL 22 <br />FROM <br />092800 <br /> <br />A <br /> <br />ST.~TEMENT COVERS PERIOD <br />THROUGH <br />092800 <br /> <br />68 CERT.-SSN.-HIC.-ID. NO. 475428767 <br /> <br />STRONG <br /> <br />PHYLLIS <br /> <br />DETAIL OF CHARGES <br /> <br />R CODE <br /> <br />DATE <br /> <br />DESCRIPTION <br /> <br />AMOUNT <br /> <br />R. COOE <br /> <br />DATE <br /> <br />DESCRIPTION <br /> <br />AMOUNT <br /> <br />LIABILITY WITH MEDICARE <br /> <br />253 09-28 TAKE HOME DRUGS 12.78 <br />TOTAL 0253-DRUGS/TAKEHOME <br /> <br />12.78 <br /> <br />320 09-28 CHEST 2 VIEWS <br />TOTAL 0320-DX <br /> <br />152.64 <br />X-RAY <br /> <br />152.64 <br /> <br />450 09-28 LEVEL III 220.00 <br />TOTAL 0450-EMERG ROOM <br /> <br />220.00 <br /> <br />TOTAL CHARGES <br /> <br />385.42 <br />