STATEMENT

Jordan S. Sparks, DMD 05112/2005

1462 Commercial St SE Account Number 3022
Salem, OR 97302
(503)363-5432 Aniounlouo Diliouo IAmount Eootolld
90.00 Upon Receipt

CREDIT CARO TYP E

·-----------------
Jason Spander
1462 Commercial St SE '"""'- - - - - - - - - - - - - - -
AIIIOUNTAP PRO\IEO _ _ _ _ _ _ _ _ _ _ __
Salem, OR 97302
- - - - - - -= = ==- - - - - -
~ l "((<M'II o,, •~

.,..
111.00
.....
0 .00
.....
0 .00
....
0 .00
T
111.00
• IOIIE■
21.00
........
90.00
Spander, Jason
•~le Code Toolh Description Fee Ins E st Ins P Patie,, Adj Paid Balance
10/29/2004 D1110 Prophy-Adul 72.00 72.00 72.00 0 .00 0 .00
10/29/2004 Ins PriC 1aim S72.00 Aetna I ~ceived 0 .00
11/02/2004 D7140 31 Extraction 105.00 105.00 24.00 60.00 60.00
11/02/2004 00150 Comprehensive E)(81Tl 60.00 60.00 60.00 0 .00 60.00
11/02/2004 00330 Panoramic film 83.00 83.00 83.00 0 .00 60.00
11/02/2004 00272 BitewinA-2 films 35.00 35.00 35.00 0 .00 60.00
11/02/2004 Ins PriC1aim S283.00 Aetna F!e,ceived 60.00
11/02/2004 Ins SecC1aim S105.00 Provid9nce Hold 60.00
11/02/2004 Adiust Cash Discount -6.00 54.00
11/02/2004 Pav Cash S54 .00 -54 .00 0 .00
11/02/2004 Comm Sent Ststerrent
01/28/2005 02140 1 9 Amall:lsm-1 Surf 80.00 0 .00 Unsen 80.00 80.00
01/28/2005 Pay CheckS100.00 (spit) -80.00 0 .00
b 5i09/2005 D521 3 fi.<\axillsry RPO no39.00 469.50 469.50 569.50 -100.00 -469.50 0 .00
05/09/2005 Ins PriC1aimS1 .039.00 Aetna. Ded a ppfed I ~ceived 0 .00
b 5i09/2005 Pay Check$469.50 0 .00
n5112noo5 Comm Sent Stste rrent
0.00
Spander, Julie A
......
07/23/2003
Code Toolh Descri-on
U0001 Conversion needs to be verifed
Fee Ins Est Ins P
0 .00
Patir
0 .00
Adj Paid Balance
0 .00
03/12/2004 00120 Periodic Exam 42.00 42.00 42.00
b3t12/2004 D1110 Prophv- Adul 68.00 68.00 11 0.00
n1128noo5 Pav S"lit'01/28/2005 -20.00 90.00
90.00
Hsve a grea tdsy