Spokane Regional Health District

1001 W College Ave

Spokane, WA 99201-2095
509.324.1420 | TEL
509.327.0163 | FAX
509.324.1464 | TDD
www.SRHD.org

Patient Name: BYRON CLAFLIN

MRN #: 07732321
INS: Self pay
Address: 1728 E Olympic Ave, Spokane, WA, 99207
Phone #: 5096551704

CPT CODE DOS(DATE OF SERVICE) DESCRIPTION OF SERVICE QUA(QUANTITY) TOTAL AMOUNT

G2067 3/19/23-3/25/23 Med assist tx meth wk $215.67

1
G2067 3/26/23-4/1/23 Med assist tx meth wk 1 $215.67

G2080 3/27/23 Add 30 mins counsel $32.03

1
G2067 4/2/23-4/8/23 Med assist tx meth wk 1 $215.67

G2067 4/9/23-4/15/23 Med assist tx meth wk $215.67

1
G2067 4/16/23-4/22/23 Med assist tx meth wk 1 $215.67

G2080 4/20/23 Add 30 mins counsel $32.03

1
G2078 4/21/23 Take-home meth 1 $37.38

G2067 4/23/23-4/29/23 Med assist tx meth wk $215.67

1
G2067 4/30/23-5/6/23 Med assist tx meth wk 1 $215.67

G2067 5/7/23-5/13/23 Med assist tx meth wk $215.67

1
G2080 5/9/23 Add 30 mins counsel 1 $32.03

G2067 5/14/23-5/20/23 Med assist tx meth wk $215.67

1
G2067 5/21/23-5/27/23 Med assist tx meth wk 1 $215.67

TOTAL CHARGES $2,290.17

RECEIVED PAYMENTS 5/17/23 $2,250.00
PAYMENT DUE 6/26/23 $40.17
TOTAL PATIENT BALANCE DUE $40.17
Spokane Regional Health District
1001 W College Ave
Spokane, WA 99201-2095
509.324.1420 | TEL
509.327.0163 | FAX
509.324.1464 | TDD
www.SRHD.org