 |
Claims by Claim Number |  |
| By Group Code | Report Date: 11/04/2003 |
| By Plan | Report Period: 10/01/2003 - 10/31/2003 Paid |
| By Location |
Claim
Enrollee
Dep
Dates
SSN
First
Charges
Disallowed
Allowable
Disc
Deduct
Pays
OOP
Reimb
Sav
Other
Paid
Status
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Claim |
Enrollee |
Dep |
Incurred Dates |
SSN |
Mem First |
Charges |
Disallowed |
Allowable |
PPO Disc |
Deduct |
Co- Pays |
Coins OOP |
COB Reimb |
COB Sav |
Other |
Paid |
Claim Status | |||||||
| Group: 99999 | ||||||||||||||||||||||||
| Plan: 99999A | ||||||||||||||||||||||||
| Location: 0000 | ||||||||||||||||||||||||
| Benefit Type: CS | ||||||||||||||||||||||||
| 3049449302 | DOE, J | e | 09/26-09/26/2003 | 123456789 | PAT | $346.00 | $.00 | $346.00 | $143.55 | $.00 | $.00 | $60.73 | $.00 | $.00 | $.00 | $141.72 | f | |||||||
| 3051870502 | DOE, J | e | 10/31-10/31/2003 | 123456789 | PAT | $245.00 | $.00 | $245.00 | $4.38 | $.00 | $.00 | $72.19 | $.00 | $.00 | $.00 | $168.43 | f | |||||||
| 3051892802 | DOE, J | 4 | 09/04-09/05/2003 | 123456789 | PAT | $2,382.21 | $.00 | $2,382.21 | $673.92 | $.00 | $50.00 | $165.83 | $.00 | $.00 | $.00 | $1,492.46 | f | |||||||
| 3052002601 | DOE, J | s | 12/03-12/07/2003 | 123456789 | PAT | $30,240.12 | $.00 | $30,240.12 | $1,512.01 | $.00 | $500.00 | $1,601.29 | $.00 | $.00 | $.00 | $26,626.82 | f | |||||||
| 4001604301 | DOE, J | e | 10/29-10/31/2003 | 123456789 | PAT | $3,585.00 | $.00 | $3,585.00 | $179.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $3,405.75 | f | |||||||
| 4001604701 | DOE, J | e | 11/01-11/07/2003 | 123456789 | PAT | $8,365.00 | $.00 | $8,365.00 | $418.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $7,946.75 | f | |||||||
| 4001607001 | DOE, J | e | 12/01-12/05/2003 | 123456789 | PAT | $2,875.00 | $.00 | $2,875.00 | $143.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $2,731.25 | f | |||||||
| 4001610302 | DOE, J | 1 | 12/10-12/12/2003 | 123456789 | PAT | $223.00 | $.00 | $223.00 | $48.05 | $174.95 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4001666302 | DOE, J | 2 | 12/12-12/12/2003 | 123456789 | PAT | $162.00 | $.00 | $162.00 | $16.20 | $55.80 | $.00 | $27.00 | $.00 | $.00 | $.00 | $63.00 | f | |||||||
| 4001690402 | DOE, J | e | 12/02-12/02/2003 | 123456789 | PAT | $857.68 | $.00 | $857.68 | $128.65 | $.00 | $.00 | $189.54 | $.00 | $.00 | $.00 | $539.49 | f | |||||||
| 4002409402 | DOE, J | 1 | 12/15-12/19/2003 | 123456789 | PAT | $190.00 | $.00 | $190.00 | $36.12 | $75.05 | $.00 | $31.54 | $.00 | $.00 | $.00 | $47.29 | f | |||||||
| 4002456202 | DOE, J | 1 | 12/22-12/29/2003 | 123456789 | PAT | $279.00 | $.00 | $279.00 | $43.64 | $.00 | $.00 | $94.15 | $.00 | $.00 | $.00 | $141.21 | f | |||||||
| 4002480101 | DOE, J | s | 01/02-01/02/2004 | 123456789 | PAT | $185.00 | $185.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4002583601 | DOE, J | s | 01/05-01/05/2004 | 123456789 | PAT | $130.00 | $130.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4002927201 | DOE, J | e | 12/02-12/02/2003 | 123456789 | PAT | $195.00 | $.00 | $195.00 | $68.25 | $120.25 | $.00 | $1.95 | $.00 | $.00 | $.00 | $4.55 | f | |||||||
| 4002927501 | DOE, J | e | 12/08-12/08/2003 | 123456789 | PAT | $167.00 | $.00 | $167.00 | $16.70 | $.00 | $.00 | $45.09 | $.00 | $.00 | $.00 | $105.21 | f | |||||||
| 4002972901 | DOE, J | e | 12/23-12/23/2003 | 123456789 | PAT | $234.25 | $.00 | $234.25 | $136.25 | $.00 | $.00 | $29.40 | $.00 | $.00 | $.00 | $68.60 | f | |||||||
| 4002973501 | DOE, J | 1 | 12/15-12/15/2003 | 123456789 | PAT | $225.00 | $.00 | $225.00 | $90.00 | $49.00 | $.00 | $25.80 | $.00 | $.00 | $.00 | $60.20 | f | |||||||
| 4002991301 | DOE, J | s | 12/09-12/09/2003 | 123456789 | PAT | $208.00 | $.00 | $208.00 | $52.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $156.00 | f | |||||||
| 4002991701 | DOE, J | e | 12/16-12/16/2003 | 123456789 | PAT | $3,412.50 | $3,412.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4002993801 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $78.00 | $.00 | $78.00 | $14.50 | $63.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4002995101 | DOE, J | e | 12/10-12/10/2003 | 123456789 | PAT | $2,534.00 | $.00 | $2,534.00 | $760.20 | $.00 | $.00 | $709.52 | $.00 | $.00 | $.00 | $1,064.28 | f | |||||||
| 4002997501 | DOE, J | s | 12/03-12/03/2003 | 123456789 | PAT | $87.00 | $.00 | $87.00 | $23.50 | $63.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003048101 | DOE, J | s | 01/02-01/02/2004 | 123456789 | PAT | $70.00 | $.00 | $70.00 | $24.50 | $45.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003048601 | DOE, J | 1 | 01/02-01/09/2004 | 123456789 | PAT | $325.00 | $325.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003048602 | DOE, J | 1 | 01/02-01/09/2004 | 123456789 | PAT | $325.00 | $.00 | $325.00 | $62.60 | $.00 | $.00 | $104.97 | $.00 | $.00 | $.00 | $157.43 | f | |||||||
| 4003050801 | DOE, J | s | 01/11-01/11/2004 | 123456789 | PAT | $332.07 | $.00 | $332.07 | $99.62 | $232.45 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003051201 | DOE, J | e | 10/03-10/03/2003 | 123456789 | PAT | $142.00 | $.00 | $142.00 | $21.30 | $.00 | $.00 | $36.21 | $.00 | $.00 | $.00 | $84.49 | f | |||||||
| 4003053301 | DOE, J | 3 | 02/05-02/21/2003 | 123456789 | PAT | $436.50 | $226.50 | $210.00 | $31.50 | $.00 | $.00 | $53.55 | $.00 | $.00 | $.00 | $124.95 | f | |||||||
| 4003053501 | DOE, J | 2 | 01/07-01/07/2004 | 123456789 | PAT | $190.00 | $.00 | $190.00 | $19.00 | $55.80 | $.00 | $39.46 | $.00 | $.00 | $.00 | $75.74 | f | |||||||
| 4003054401 | DOE, J | s | 12/17-12/17/2003 | 123456789 | WENDY V | $33.00 | $33.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003055501 | DOE, J | s | 12/26-12/26/2003 | 123456789 | PAT | $680.00 | $.00 | $680.00 | $140.00 | $.00 | $.00 | $162.00 | $.00 | $.00 | $.00 | $378.00 | f | |||||||
| 4003056001 | DOE, J | s | 07/02-07/02/2003 | 123456789 | PAT | $175.00 | $175.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003056401 | DOE, J | s | 07/02-07/02/2003 | 123456789 | PAT | $645.25 | $645.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003058501 | DOE, J | s | 01/03-01/04/2004 | 123456789 | PAT | $395.00 | $395.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003063001 | DOE, J | s | 01/02-01/02/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $53.18 | $.00 | $.00 | $8.05 | $.00 | $.00 | $.00 | $18.77 | f | |||||||
| 4003063501 | DOE, J | s | 01/02-01/02/2004 | 123456789 | PAT | $200.00 | $.00 | $200.00 | $121.47 | $.00 | $.00 | $23.56 | $.00 | $.00 | $.00 | $54.97 | f | |||||||
| 4003064201 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $285.00 | $.00 | $285.00 | $57.00 | $228.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003065101 | DOE, J | 1 | 01/06-01/06/2004 | 123456789 | PAT | $125.00 | $.00 | $125.00 | $25.00 | $100.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003066001 | DOE, J | s | 01/08-01/08/2004 | 123456789 | PAT | $85.00 | $85.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003066002 | DOE, J | s | 01/08-01/08/2004 | 123456789 | PAT | $85.00 | $.00 | $85.00 | $17.00 | $68.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003096601 | DOE, J | s | 01/03-01/03/2004 | 123456789 | PAT | $1,721.00 | $.00 | $1,721.00 | $430.25 | $250.00 | $.00 | $312.22 | $.00 | $.00 | $.00 | $728.53 | f | |||||||
| 4003100501 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $20.00 | $.00 | $20.00 | $2.00 | $.00 | $.00 | $5.40 | $.00 | $.00 | $.00 | $12.60 | f | |||||||
| 4003101301 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $113.50 | $.00 | $113.50 | $11.35 | $.00 | $.00 | $30.64 | $.00 | $.00 | $.00 | $71.51 | f | |||||||
| 4003102501 | DOE, J | s | 01/09-01/09/2004 | 123456789 | PAT | $3,000.00 | $.00 | $3,000.00 | $300.00 | $42.00 | $.00 | $797.40 | $.00 | $.00 | $.00 | $1,860.60 | f | |||||||
| 4003103801 | DOE, J JR | 1 | 10/04-10/14/2003 | 123456789 | PAT | $399.00 | $.00 | $399.00 | $79.80 | $.00 | $.00 | $95.76 | $.00 | $.00 | $.00 | $223.44 | f | |||||||
| 4003105001 | DOE, J | 2 | 01/11-01/11/2004 | 123456789 | PAT | $110.00 | $.00 | $110.00 | $38.50 | $71.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003123901 | DOE, J | s | 01/14-01/14/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $32.00 | $.00 | $.00 | $14.40 | $.00 | $.00 | $.00 | $33.60 | f | |||||||
| 4003180401 | DOE, J | e | 12/24-12/24/2003 | 123456789 | PAT | $4,752.06 | $.00 | $4,752.06 | $3,452.06 | $.00 | $100.00 | $360.00 | $.00 | $.00 | $.00 | $840.00 | f | |||||||
| 4003195101 | DOE, J | e | 12/19-12/19/2003 | 123456789 | PAT | $595.00 | $.00 | $595.00 | $59.50 | $250.00 | $.00 | $85.65 | $.00 | $.00 | $.00 | $199.85 | f | |||||||
| 4003195901 | DOE, J | e | 11/21-11/21/2003 | 123456789 | PAT | $680.00 | $.00 | $680.00 | $68.00 | $.00 | $.00 | $183.60 | $.00 | $.00 | $.00 | $428.40 | f | |||||||
| 4003198601 | DOE, J | 1 | 10/21-10/21/2003 | 123456789 | PAT | $84.00 | $.00 | $84.00 | $31.00 | $.00 | $.00 | $26.50 | $.00 | $.00 | $.00 | $26.50 | f | |||||||
| 4003332701 | DOE, J | e | 06/10-06/10/2003 | 123456789 | PAT | $205.00 | $.00 | $205.00 | $53.71 | $151.29 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003333601 | DOE, J | 2 | 01/14-01/14/2004 | 123456789 | PAT | $315.00 | $.00 | $315.00 | $116.92 | $.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $188.08 | f | |||||||
| 4003334501 | DOE, J | e | 10/28-10/28/2003 | 123456789 | PAT | $72.00 | $72.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003366801 | DOE, J | s | 12/27-12/29/2003 | 123456789 | PAT | $750.00 | $750.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003367101 | DOE, J | s | 12/30-12/30/2003 | 123456789 | PAT | $250.00 | $250.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003367301 | DOE, J | s | 12/31-12/31/2003 | 123456789 | PAT | $250.00 | $250.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003367901 | DOE, J | s | 01/01-01/02/2004 | 123456789 | PAT | $500.00 | $500.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003371601 | DOE, J | e | 12/01-12/15/2003 | 123456789 | PAT | $1,903.72 | $.00 | $1,903.72 | $443.62 | $.00 | $.00 | $470.85 | $.00 | $.00 | $.00 | $989.25 | f | |||||||
| 4003372401 | DOE, J | s | 10/17-10/17/2003 | 123456789 | PAT | $70.40 | $70.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003419001 | DOE, J | s | 12/12-12/12/2003 | 123456789 | PAT | $50.00 | $.00 | $50.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $35.00 | f | |||||||
| 4003419801 | DOE, J | s | 10/21-10/21/2003 | 123456789 | PAT | $2,750.00 | $.00 | $2,750.00 | $470.36 | $.00 | $.00 | $683.89 | $.00 | $.00 | $.00 | $1,595.75 | f | |||||||
| 4003424001 | DOE, J | e | 12/18-12/18/2003 | 123456789 | PAT | $2,615.50 | $.00 | $2,615.50 | $261.55 | $250.00 | $.00 | $1,386.45 | $.00 | $.00 | $.00 | $717.50 | f | |||||||
| 4003424601 | DOE, J | s | 08/21-08/21/2003 | 123456789 | PAT | $150.00 | $150.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003427401 | DOE, J | 3 | 01/07-01/24/2003 | 123456789 | PAT | $150.00 | $150.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003448701 | DOE, J | e | 12/16-12/31/2003 | 123456789 | PAT | $1,236.29 | $.00 | $1,236.29 | $186.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1,049.89 | f | |||||||
| 4003640501 | DOE, J | s | 10/20-10/21/2003 | 123456789 | PAT | $170.00 | $170.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003702401 | DOE, J | s | 10/22-10/22/2003 | 123456789 | KAREN R | $37.00 | $.00 | $37.00 | $13.30 | $.00 | $.00 | $7.11 | $.00 | $.00 | $.00 | $16.59 | f | |||||||
| 4003702701 | DOE, J JR | e | 01/07-01/07/2004 | 123456789 | JAIME JR | $1,400.00 | $.00 | $1,400.00 | $210.00 | $.00 | $.00 | $357.00 | $.00 | $.00 | $.00 | $833.00 | f | |||||||
| 4003708101 | DOE, J | s | 01/12-01/12/2004 | 123456789 | PAT | $130.00 | $130.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003709101 | DOE, J | s | 01/09-01/09/2004 | 123456789 | PAT | $45.00 | $.00 | $45.00 | $5.67 | $39.33 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003709701 | DOE, J | s | 01/08-01/08/2004 | 123456789 | PAT | $70.00 | $.00 | $70.00 | $14.00 | $56.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003714301 | DOE, J | e | 01/07-01/07/2004 | 123456789 | PAT | $1,104.00 | $1,104.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003714302 | DOE, J | e | 01/07-01/07/2004 | 123456789 | PAT | $1,104.00 | $.00 | $1,104.00 | $165.60 | $.00 | $.00 | $281.52 | $.00 | $.00 | $.00 | $656.88 | f | |||||||
| 4003715501 | DOE, J | e | 11/10-11/10/2003 | 123456789 | PAT | $85.00 | $.00 | $85.00 | $15.61 | $.00 | $.00 | $20.82 | $.00 | $.00 | $.00 | $48.57 | f | |||||||
| 4003716401 | DOE, J | e | 01/12-01/12/2004 | 123456789 | PAT | $60.00 | $.00 | $60.00 | $6.90 | $53.10 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003716601 | DOE, J | e | 12/05-12/05/2003 | 123456789 | PAT | $120.00 | $.00 | $120.00 | $20.88 | $.00 | $.00 | $29.74 | $.00 | $.00 | $.00 | $69.38 | f | |||||||
| 4003762201 | DOE, J | 1 | 12/03-12/03/2003 | 123456789 | PAT | $405.95 | $.00 | $405.95 | $20.30 | $35.00 | $50.00 | $90.19 | $.00 | $.00 | $.00 | $210.46 | f | |||||||
| 4003762701 | DOE, J | 3 | 12/03-12/03/2003 | 123456789 | PAT | $401.66 | $.00 | $401.66 | $20.08 | $248.00 | $50.00 | $25.07 | $.00 | $.00 | $.00 | $58.51 | f | |||||||
| 4003779101 | DOE, J | s | 12/29-01/05/2004 | 123456789 | PAT | $674.00 | $674.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4003779201 | DOE, J | s | 08/05-08/05/2003 | 123456789 | PAT | $54.00 | $.00 | $54.00 | $5.40 | $.00 | $.00 | $14.58 | $.00 | $.00 | $.00 | $34.02 | f | |||||||
| 4003779501 | DOE, J | s | 08/05-08/05/2003 | 123456789 | PAT | $40.00 | $.00 | $40.00 | $4.00 | $.00 | $.00 | $12.20 | $.00 | $.00 | $.00 | $23.80 | f | |||||||
| 4003779701 | DOE, J | s | 08/05-08/05/2003 | 123456789 | PAT | $145.00 | $.00 | $145.00 | $14.50 | $.00 | $.00 | $39.15 | $.00 | $.00 | $.00 | $91.35 | f | |||||||
| 4003989701 | DOE, J | 2 | 01/11-01/11/2004 | 123456789 | PAT | $365.00 | $365.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004018601 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $80.00 | $80.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004018801 | DOE, J | s | 01/09-01/09/2004 | 123456789 | PAT | $128.00 | $128.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004019301 | DOE, J | 3 | 12/05-12/05/2003 | 123456789 | PAT | $56.00 | $56.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004028701 | DOE, J | s | 12/30-01/29/2004 | 123456789 | PAT | $385.00 | $.00 | $385.00 | $97.00 | $185.00 | $.00 | $30.90 | $.00 | $.00 | $.00 | $72.10 | f | |||||||
| 4004097601 | DOE, J | e | 01/06-01/07/2004 | 123456789 | PAT | $69.33 | $.00 | $69.33 | $14.43 | $16.90 | $.00 | $11.40 | $.00 | $.00 | $.00 | $26.60 | f | |||||||
| 4004097701 | DOE, J | e | 01/08-01/09/2004 | 123456789 | PAT | $77.27 | $.00 | $77.27 | $8.13 | $.00 | $.00 | $20.74 | $.00 | $.00 | $.00 | $48.40 | f | |||||||
| 4004097901 | DOE, J | e | 01/09-01/12/2004 | 123456789 | PAT | $62.14 | $.00 | $62.14 | $4.27 | $.00 | $.00 | $17.37 | $.00 | $.00 | $.00 | $40.50 | f | |||||||
| 4004108201 | DOE, J | e | 07/30-07/30/2003 | 123456789 | PAT | $236.00 | $236.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004109401 | DOE, J | e | 08/18-08/18/2003 | 123456789 | PAT | $206.00 | $206.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004118701 | DOE, J | 1 | 09/27-09/27/2002 | 123456789 | PAT | $24.00 | $24.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004234001 | DOE, J | s | 01/05-01/05/2004 | 123456789 | PAT | $322.50 | $.00 | $322.50 | $64.50 | $.00 | $.00 | $51.60 | $.00 | $.00 | $.00 | $206.40 | f | |||||||
| 4004350201 | DOE, J JR | e | 01/16-01/18/2004 | 123456789 | JAIME JR | $305.00 | $.00 | $305.00 | $48.98 | $.00 | $.00 | $76.80 | $.00 | $.00 | $.00 | $179.22 | f | |||||||
| 4004350301 | DOE, J JR | e | 01/15-01/15/2004 | 123456789 | JAIME JR | $95.00 | $.00 | $95.00 | $19.52 | $.00 | $.00 | $22.64 | $.00 | $.00 | $.00 | $52.84 | f | |||||||
| 4004351901 | DOE, J | s | 01/06-01/06/2004 | 123456789 | PAT | $789.35 | $.00 | $789.35 | $39.46 | $.00 | $.00 | $224.97 | $.00 | $.00 | $.00 | $524.92 | f | |||||||
| 4004352401 | DOE, J IV | 2 | 10/11-10/11/2003 | 123456789 | PAT | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004352501 | DOE, J IV | 1 | 10/11-10/11/2003 | 123456789 | WILLIAM V | $65.00 | $65.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004352701 | DOE, J | s | 01/12-01/12/2004 | 123456789 | PAT | $25.00 | $.00 | $25.00 | $5.00 | $.00 | $.00 | $6.00 | $.00 | $.00 | $.00 | $14.00 | f | |||||||
| 4004386401 | DOE, J | s | 01/16-01/16/2004 | 123456789 | PAT | $45.00 | $.00 | $45.00 | $4.50 | $.00 | $.00 | $12.15 | $.00 | $.00 | $.00 | $28.35 | f | |||||||
| 4004441001 | DOE, J | 2 | 12/31-12/31/2003 | 123456789 | PAT | $37.00 | $37.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004441101 | DOE, J | e | 01/13-01/13/2004 | 123456789 | PAT | $58.00 | $.00 | $58.00 | $5.80 | $52.20 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004441201 | DOE, J | e | 01/19-01/19/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $8.00 | $72.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004441301 | DOE, J | 3 | 01/08-01/08/2004 | 123456789 | PAT | $70.00 | $70.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004441401 | DOE, J | 1 | 01/16-01/16/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $30.00 | $.00 | $.00 | $25.00 | $.00 | $.00 | $.00 | $25.00 | f | |||||||
| 4004441501 | DOE, J | s | 10/30-10/30/2003 | 123456789 | PAT | $185.00 | $185.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004441701 | DOE, J | e | 01/16-01/16/2004 | 123456789 | PAT | $74.00 | $.00 | $74.00 | $14.80 | $59.20 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004478601 | DOE, J | 1 | 01/09-01/09/2004 | 123456789 | PAT | $86.00 | $.00 | $86.00 | $17.20 | $68.80 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004509301 | DOE, J | 1 | 01/23-01/23/2004 | 123456789 | PAT | $100.00 | $.00 | $100.00 | $21.69 | $.00 | $.00 | $39.15 | $.00 | $.00 | $.00 | $39.16 | f | |||||||
| 4004513701 | DOE, J | e | 11/23-11/23/2003 | 123456789 | PAT | $204.00 | $204.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004514301 | DOE, J | s | 01/20-01/20/2004 | 123456789 | PAT | $73.00 | $.00 | $73.00 | $7.52 | $.00 | $.00 | $19.64 | $.00 | $.00 | $.00 | $45.84 | f | |||||||
| 4004516101 | DOE, J JR | 1 | 01/16-01/16/2004 | 123456789 | PAT | $60.00 | $.00 | $60.00 | $18.86 | $41.14 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004516801 | DOE, J | e | 01/19-01/19/2004 | 123456789 | PAT | $176.00 | $176.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004517601 | DOE, J | e | 12/28-12/28/2003 | 123456789 | PAT | $312.00 | $312.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004527201 | DOE, J | e | 01/08-01/09/2004 | 123456789 | PAT | $475.00 | $475.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004535501 | DOE, J | s | 01/23-01/23/2004 | 123456789 | PAT | $63.00 | $.00 | $63.00 | $7.56 | $55.44 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004536001 | DOE, J | s | 01/23-01/23/2004 | 123456789 | PAT | $175.00 | $.00 | $175.00 | $30.34 | $144.66 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004536401 | DOE, J | e | 11/19-11/19/2003 | 123456789 | PAT | $345.00 | $.00 | $345.00 | $221.68 | $.00 | $.00 | $37.00 | $.00 | $.00 | $.00 | $86.32 | f | |||||||
| 4004536801 | DOE, J | e | 10/17-10/17/2003 | 123456789 | PAT | $150.00 | $.00 | $150.00 | $30.00 | $109.00 | $.00 | $11.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004574701 | DOE, J | s | 01/11-01/11/2004 | 123456789 | PAT | $222.00 | $.00 | $222.00 | $127.05 | $94.95 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004579301 | DOE, J | s | 09/15-09/15/2003 | 123456789 | PAT | $45.00 | $18.00 | $27.00 | $.00 | $27.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004656401 | DOE, J | s | 06/03-06/03/2003 | 123456789 | PAT | $52.00 | $.00 | $52.00 | $4.00 | $48.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004657301 | DOE, J JR | e | 01/21-01/22/2004 | 123456789 | JAIME JR | $190.00 | $.00 | $190.00 | $39.04 | $.00 | $.00 | $45.28 | $.00 | $.00 | $.00 | $105.68 | f | |||||||
| 4004657901 | DOE, J | e | 01/08-01/08/2004 | 123456789 | PAT | $95.00 | $.00 | $95.00 | $14.70 | $80.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004658301 | DOE, J | e | 08/05-08/05/2003 | 123456789 | PAT | $165.00 | $165.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004659201 | DOE, J | e | 08/04-08/04/2003 | 123456789 | PAT | $165.00 | $165.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004685601 | DOE, J | s | 01/09-02/08/2004 | 123456789 | PAT | $690.00 | $.00 | $690.00 | $355.01 | $.00 | $.00 | $134.00 | $.00 | $.00 | $.00 | $200.99 | f | |||||||
| 4004685901 | DOE, J | s | 12/09-01/08/2004 | 123456789 | PAT | $690.00 | $.00 | $690.00 | $355.01 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $334.99 | f | |||||||
| 4004691101 | DOE, J | e | 01/08-01/08/2004 | 123456789 | PAT | $131.00 | $131.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004692501 | DOE, J | s | 12/31-12/31/2003 | 123456789 | PAT | $35.00 | $.00 | $35.00 | $7.00 | $.00 | $.00 | $2.80 | $.00 | $.00 | $.00 | $25.20 | f | |||||||
| 4004703201 | DOE, J | s | 01/16-01/16/2004 | 123456789 | PAT | $247.00 | $.00 | $247.00 | $131.82 | $41.50 | $.00 | $22.11 | $.00 | $.00 | $.00 | $51.57 | f | |||||||
| 4004703301 | DOE, J | e | 01/20-01/20/2004 | 123456789 | PAT | $122.00 | $.00 | $122.00 | $14.21 | $63.79 | $.00 | $13.20 | $.00 | $.00 | $.00 | $30.80 | f | |||||||
| 4004711301 | DOE, J JR | e | 01/23-01/23/2004 | 123456789 | JAIME JR | $95.00 | $.00 | $95.00 | $19.52 | $.00 | $.00 | $22.64 | $.00 | $.00 | $.00 | $52.84 | f | |||||||
| 4004711401 | DOE, J | e | 12/31-12/31/2003 | 123456789 | PAT | $95.00 | $.00 | $95.00 | $14.70 | $.00 | $.00 | $32.12 | $.00 | $.00 | $.00 | $48.18 | f | |||||||
| 4004711501 | DOE, J | 2 | 01/07-01/07/2004 | 123456789 | PAT | $561.00 | $.00 | $561.00 | $56.10 | $54.67 | $.00 | $45.02 | $.00 | $.00 | $.00 | $405.21 | f | |||||||
| 4004716801 | DOE, J | s | 10/22-10/22/2003 | 123456789 | PAT | $272.00 | $272.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004717601 | DOE, J | e | 01/20-01/20/2004 | 123456789 | PAT | $75.00 | $.00 | $75.00 | $9.00 | $66.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004718501 | DOE, J | s | 01/14-01/14/2004 | 123456789 | PAT | $60.00 | $.00 | $60.00 | $6.00 | $.00 | $.00 | $16.20 | $.00 | $.00 | $.00 | $37.80 | f | |||||||
| 4004719301 | DOE, J | s | 02/28-02/28/2003 | 123456789 | PAT | $180.00 | $.00 | $180.00 | $26.00 | $154.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4004987001 | DOE, J | s | 12/19-12/31/2003 | 123456789 | PAT | $405.00 | $.00 | $405.00 | $141.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $263.25 | f | |||||||
| 4004995701 | DOE, J | 3 | 01/01-01/02/2004 | 123456789 | PAT | $4,802.00 | $.00 | $4,802.00 | $1,440.60 | $500.00 | $50.00 | $843.42 | $.00 | $.00 | $.00 | $1,967.98 | f | |||||||
| 4005020201 | DOE, J | e | 01/15-01/15/2004 | 123456789 | PAT | $35.00 | $.00 | $35.00 | $26.73 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $8.27 | f | |||||||
| 4005032001 | DOE, J | s | 01/23-01/23/2004 | 123456789 | PAT | $770.00 | $.00 | $770.00 | $341.60 | $244.02 | $.00 | $55.31 | $.00 | $.00 | $.00 | $129.07 | f | |||||||
| 4005032801 | DOE, J | e | 01/16-01/16/2004 | 123456789 | PAT | $85.00 | $.00 | $85.00 | $16.00 | $65.00 | $.00 | $1.20 | $.00 | $.00 | $.00 | $2.80 | f | |||||||
| 4005033201 | DOE, J | e | 01/12-01/12/2004 | 123456789 | PAT | $140.00 | $.00 | $140.00 | $49.99 | $65.00 | $.00 | $7.50 | $.00 | $.00 | $.00 | $17.51 | f | |||||||
| 4005033701 | DOE, J | e | 01/09-01/09/2004 | 123456789 | PAT | $920.00 | $.00 | $920.00 | $398.75 | $65.00 | $.00 | $136.87 | $.00 | $.00 | $.00 | $319.38 | f | |||||||
| 4005062501 | DOE, J | e | 02/06-02/06/2004 | 123456789 | PAT | $78.00 | $.00 | $78.00 | $22.85 | $55.15 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005062601 | DOE, J | 3 | 01/09-01/09/2004 | 123456789 | PAT | $265.00 | $.00 | $265.00 | $204.21 | $.00 | $.00 | $18.22 | $.00 | $.00 | $.00 | $42.57 | f | |||||||
| 4005081601 | DOE, J | e | 12/15-01/14/2004 | 123456789 | PAT | $370.00 | $.00 | $370.00 | $131.00 | $185.00 | $.00 | $16.20 | $.00 | $.00 | $.00 | $37.80 | f | |||||||
| 4005081901 | DOE, J | e | 01/26-01/26/2004 | 123456789 | PAT | $208.00 | $.00 | $208.00 | $64.24 | $81.00 | $.00 | $18.83 | $.00 | $.00 | $.00 | $43.93 | f | |||||||
| 4005096901 | DOE, J | s | 12/05-12/05/2003 | 123456789 | PAT | $103.00 | $103.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005098001 | DOE, J JR | 3 | 01/21-01/21/2004 | 123456789 | PAT | $155.00 | $.00 | $155.00 | $54.25 | $100.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005105601 | DOE, J JR | 3 | 01/19-01/19/2004 | 123456789 | PAT | $332.00 | $.00 | $332.00 | $116.20 | $182.25 | $.00 | $16.71 | $.00 | $.00 | $.00 | $16.84 | f | |||||||
| 4005120601 | DOE, J | e | 01/06-01/06/2004 | 123456789 | PAT | $66.00 | $.00 | $66.00 | $6.60 | $59.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005121201 | DOE, J | e | 10/05-10/05/2003 | 123456789 | PAT | $90.50 | $90.50 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005121202 | DOE, J | e | 10/05-10/05/2003 | 123456789 | PAT | $90.50 | $.00 | $90.50 | $47.50 | $43.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005121301 | DOE, J | s | 12/08-12/08/2003 | 123456789 | PAT | $40.00 | $.00 | $40.00 | $16.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $23.70 | f | |||||||
| 4005122401 | DOE, J | s | 01/26-01/26/2004 | 123456789 | PAT | $58.00 | $.00 | $58.00 | $9.01 | $48.99 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005122801 | DOE, J | 1 | 02/04-02/04/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $15.83 | $.00 | $.00 | $32.08 | $.00 | $.00 | $.00 | $32.09 | f | |||||||
| 4005123001 | DOE, J | s | 02/02-02/02/2004 | 123456789 | PAT | $45.00 | $.00 | $45.00 | $5.08 | $39.92 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005123201 | DOE, J | e | 01/25-01/25/2004 | 123456789 | PAT | $27.00 | $.00 | $27.00 | $1.72 | $25.28 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005123301 | DOE, J | e | 02/02-02/02/2004 | 123456789 | PAT | $150.00 | $.00 | $150.00 | $60.70 | $89.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005123801 | DOE, J | 1 | 01/26-01/26/2004 | 123456789 | PAT | $83.00 | $.00 | $83.00 | $48.72 | $34.28 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005141201 | DOE, J | s | 01/16-01/16/2004 | 123456789 | PAT | $170.00 | $.00 | $170.00 | $42.50 | $.00 | $.00 | $63.75 | $.00 | $.00 | $.00 | $63.75 | f | |||||||
| 4005177001 | DOE, J | s | 01/23-01/29/2004 | 123456789 | PAT | $255.00 | $.00 | $255.00 | $77.88 | $177.12 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005177201 | DOE, J | e | 01/29-01/29/2004 | 123456789 | PAT | $45.00 | $.00 | $45.00 | $9.85 | $35.15 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005177501 | DOE, J | s | 01/26-01/26/2004 | 123456789 | PAT | $240.00 | $.00 | $240.00 | $136.79 | $100.66 | $.00 | $.77 | $.00 | $.00 | $.00 | $1.78 | f | |||||||
| 4005179901 | DOE, J | 3 | 01/13-01/13/2004 | 123456789 | PAT | $87.00 | $.00 | $87.00 | $43.35 | $43.65 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005180601 | DOE, J | s | 01/19-01/19/2004 | 123456789 | PAT | $125.00 | $.00 | $125.00 | $25.00 | $100.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005181601 | DOE, J | s | 01/30-01/30/2004 | 123456789 | PAT | $80.00 | $.00 | $80.00 | $32.00 | $.00 | $.00 | $14.40 | $.00 | $.00 | $.00 | $33.60 | f | |||||||
| 4005207401 | DOE, J | 1 | 12/22-12/22/2003 | 123456789 | PAT | $155.20 | $155.20 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005208101 | DOE, J | e | 01/10-01/10/2004 | 123456789 | PAT | $928.00 | $928.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005288901 | DOE, J | e | 01/05-01/05/2004 | 123456789 | PAT | $70.00 | $.00 | $70.00 | $7.00 | $63.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005293201 | DOE, J JR | e | 02/03-02/03/2004 | 123456789 | JAIME JR | $115.00 | $.00 | $115.00 | $9.94 | $.00 | $.00 | $31.52 | $.00 | $.00 | $.00 | $73.54 | f | |||||||
| 4005317201 | DOE, J JR | 3 | 01/26-01/26/2004 | 123456789 | PAT | $155.00 | $.00 | $155.00 | $54.25 | $100.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005354501 | DOE, J | e | 01/16-01/16/2004 | 123456789 | PAT | $175.00 | $175.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4005355601 | DOE, J | s | 01/26-01/26/2004 | 123456789 | PAT | $225.00 | $.00 | $225.00 | $56.25 | $.00 | $.00 | $84.37 | $.00 | $.00 | $.00 | $84.38 | f | |||||||
| 4005355801 | DOE, J | s | 01/28-01/28/2004 | 123456789 | PAT | $485.00 | $.00 | $485.00 | $159.50 | $250.00 | $.00 | $23.90 | $.00 | $.00 | $.00 | $51.60 | f | |||||||
| 4005428401 | DOE, J | s | 11/14-12/13/2003 | 123456789 | PAT | $385.00 | $.00 | $385.00 | $137.00 | $155.00 | $.00 | $30.90 | $.00 | $.00 | $.00 | $62.10 | f | |||||||
| Total Ben Type: CS | $114,151.45 | $14,754.35 | $99,397.10 | $17,658.94 | $7,121.24 | $810.00 | $11,147.65 | $.00 | $.00 | $.00 | $62,659.27 | |||||||||||||
| Benefit Type: D | ||||||||||||||||||||||||
| 2063287420 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $100.52 | $.00 | $100.52 | $.00 | $.00 | $.00 | $50.26 | $.00 | $.00 | $.00 | $50.26 | f | |||||||
| 2085337918 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $116.14 | $6.14 | $110.00 | $.00 | $.00 | $.00 | $55.00 | $.00 | $.00 | $.00 | $55.00 | f | |||||||
| 2114179615 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $87.50 | $.00 | $87.50 | $.00 | $.00 | $.00 | $43.75 | $.00 | $.00 | $.00 | $43.75 | f | |||||||
| 3001948715 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $67.50 | $.00 | $67.50 | $.00 | $.00 | $.00 | $33.75 | $.00 | $.00 | $.00 | $33.75 | f | |||||||
| 3003531514 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $105.08 | $38.04 | $67.04 | $.00 | $.00 | $.00 | $33.52 | $.00 | $.00 | $.00 | $33.52 | f | |||||||
| 3007056014 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $105.00 | $.00 | $105.00 | $.00 | $.00 | $.00 | $52.50 | $.00 | $.00 | $.00 | $52.50 | f | |||||||
| 3009939814 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $141.66 | $.00 | $141.66 | $.00 | $.00 | $.00 | $70.83 | $.00 | $.00 | $.00 | $70.83 | f | |||||||
| 3027135611 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $114.58 | $79.96 | $34.62 | $.00 | $.00 | $.00 | $17.31 | $.00 | $.00 | $.00 | $17.31 | f | |||||||
| 3030370710 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $116.00 | $.00 | $116.00 | $.00 | $.00 | $.00 | $58.00 | $.00 | $.00 | $.00 | $58.00 | f | |||||||
| 3034029210 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $150.00 | $.00 | $150.00 | $.00 | $.00 | $.00 | $75.00 | $.00 | $.00 | $.00 | $75.00 | f | |||||||
| 3034030810 | DOE, J | 3 | 02/09-02/09/2004 | 123456789 | PAT | $157.50 | $117.50 | $40.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | $.00 | $.00 | $20.00 | f | |||||||
| 3035083009 | DOE, J JR | 1 | 02/09-02/09/2004 | 123456789 | ADAM JR | $141.66 | $.00 | $141.66 | $.00 | $.00 | $.00 | $70.83 | $.00 | $.00 | $.00 | $70.83 | f | |||||||
| 3038565102 | DOE, J | s | 06/18-06/18/2003 | 123456789 | PAT | $320.00 | $.00 | $320.00 | $.00 | $50.00 | $.00 | $60.00 | $.00 | $.00 | $.00 | $210.00 | f | |||||||
| 3039461208 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $116.66 | $.00 | $116.66 | $.00 | $.00 | $.00 | $58.33 | $.00 | $.00 | $.00 | $58.33 | f | |||||||
| 3039472708 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $140.83 | $.00 | $140.83 | $.00 | $.00 | $.00 | $70.42 | $.00 | $.00 | $.00 | $70.41 | f | |||||||
| 3040316008 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $100.00 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $25.00 | $.00 | $.00 | $.00 | $25.00 | f | |||||||
| 3040544508 | DOE, J JR | 2 | 02/09-02/09/2004 | 123456789 | PAT | $135.00 | $.00 | $135.00 | $.00 | $.00 | $.00 | $67.50 | $.00 | $.00 | $.00 | $67.50 | f | |||||||
| 3040752608 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $113.90 | $.00 | $113.90 | $.00 | $.00 | $.00 | $56.95 | $.00 | $.00 | $.00 | $56.95 | f | |||||||
| 3041523108 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | ROLANDO JR | $98.21 | $.00 | $98.21 | $.00 | $.00 | $.00 | $49.11 | $.00 | $.00 | $.00 | $49.10 | f | |||||||
| 3041546608 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $122.66 | $.00 | $122.66 | $.00 | $.00 | $.00 | $61.33 | $.00 | $.00 | $.00 | $61.33 | f | |||||||
| 3041597308 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $125.00 | $.00 | $125.00 | $.00 | $.00 | $.00 | $62.50 | $.00 | $.00 | $.00 | $62.50 | f | |||||||
| 3042702007 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $105.08 | $.00 | $105.08 | $.00 | $.00 | $.00 | $52.54 | $.00 | $.00 | $.00 | $52.54 | f | |||||||
| 3042955207 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $130.00 | $.00 | $130.00 | $.00 | $.00 | $.00 | $65.00 | $.00 | $.00 | $.00 | $65.00 | f | |||||||
| 3043827607 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $110.00 | $.00 | $110.00 | $.00 | $.00 | $.00 | $55.00 | $.00 | $.00 | $.00 | $55.00 | f | |||||||
| 3044051306 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $50.00 | f | |||||||
| 3044160306 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $50.00 | f | |||||||
| 3044333706 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $135.20 | $.00 | $135.20 | $.00 | $.00 | $.00 | $67.60 | $.00 | $.00 | $.00 | $67.60 | f | |||||||
| 3044338306 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $170.00 | $.00 | $170.00 | $.00 | $.00 | $.00 | $85.00 | $.00 | $.00 | $.00 | $85.00 | f | |||||||
| 3045342506 | DOE, J | 3 | 02/09-02/09/2004 | 123456789 | PAT | $138.88 | $.00 | $138.88 | $.00 | $.00 | $.00 | $69.44 | $.00 | $.00 | $.00 | $69.44 | f | |||||||
| 3045919306 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $150.00 | $.00 | $150.00 | $.00 | $.00 | $.00 | $75.00 | $.00 | $.00 | $.00 | $75.00 | f | |||||||
| 3046020602 | DOE, J | s | 07/09-07/09/2003 | 123456789 | PAT | $105.00 | $.00 | $105.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $95.00 | $.00 | $10.00 | f | |||||||
| 3046724405 | DOE, J JR | 2 | 02/09-02/09/2004 | 123456789 | PAT | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $50.00 | f | |||||||
| 3046836805 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $213.33 | $.00 | $213.33 | $.00 | $.00 | $.00 | $106.67 | $.00 | $.00 | $.00 | $106.66 | f | |||||||
| 3047350105 | DOE, J | 3 | 02/09-02/09/2004 | 123456789 | PAT | $160.41 | $121.03 | $39.38 | $.00 | $.00 | $.00 | $19.69 | $.00 | $.00 | $.00 | $19.69 | f | |||||||
| 3049317704 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $125.00 | $.00 | $125.00 | $.00 | $.00 | $.00 | $62.50 | $.00 | $.00 | $.00 | $62.50 | f | |||||||
| 3049433904 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $119.00 | $.00 | $119.00 | $.00 | $.00 | $.00 | $59.50 | $.00 | $.00 | $.00 | $59.50 | f | |||||||
| 3049646304 | DOE, J JR. | 3 | 02/09-02/09/2004 | 123456789 | PAT | $143.75 | $74.99 | $68.76 | $.00 | $.00 | $.00 | $34.38 | $.00 | $.00 | $.00 | $34.38 | f | |||||||
| 3049703604 | DOE, J JR. | 1 | 02/09-02/09/2004 | 123456789 | PAT | $140.00 | $.00 | $140.00 | $.00 | $.00 | $.00 | $70.00 | $.00 | $.00 | $.00 | $70.00 | f | |||||||
| 3050372102 | DOE, J | 2 | 11/11-11/11/2003 | 123456789 | PAT | $368.00 | $.00 | $368.00 | $.00 | $.00 | $.00 | $184.00 | $.00 | $.00 | $.00 | $184.00 | f | |||||||
| 3051510003 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $133.33 | $.00 | $133.33 | $.00 | $.00 | $.00 | $66.67 | $.00 | $.00 | $.00 | $66.66 | f | |||||||
| 3051608504 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $125.00 | $.00 | $125.00 | $.00 | $.00 | $.00 | $62.50 | $.00 | $.00 | $.00 | $62.50 | f | |||||||
| 3052128703 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $166.25 | $.00 | $166.25 | $.00 | $.00 | $.00 | $83.13 | $.00 | $.00 | $.00 | $83.12 | f | |||||||
| 4001404202 | DOE, J | 2 | 12/17-12/17/2003 | 123456789 | PAT | $787.00 | $.00 | $787.00 | $.00 | $50.00 | $.00 | $368.50 | $.00 | $.00 | $.00 | $368.50 | f | |||||||
| 4001712302 | DOE, J | 1 | 01/08-01/08/2004 | 123456789 | PAT | $75.00 | $.00 | $75.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $75.00 | f | |||||||
| 4001713302 | DOE, J | s | 10/13-10/13/2003 | 123456789 | PAT | $85.00 | $85.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | f | |||||||
| 4001713303 | DOE, J | s | 08/08-08/08/2003 | 123456789 | PAT | $85.00 | $.00 | $85.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $85.00 | f | |||||||
| 4001788502 | DOE, J | e | 01/05-01/05/2004 | 123456789 | PAT | $106.00 | $.00 | $106.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $106.00 | f | |||||||
| 4001804802 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $256.25 | $.00 | $256.25 | $.00 | $.00 | $.00 | $128.13 | $.00 | $.00 | $.00 | $128.12 | f | |||||||
| 4001806302 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $50.00 | f | |||||||
| 4002037102 | DOE, J | 4 | 02/09-02/09/2004 | 123456789 | PAT | $87.00 | $.00 | $87.00 | $.00 | $.00 | $.00 | $43.50 | $.00 | $.00 | $.00 | $43.50 | f | |||||||
| 4002056102 | DOE, J | 1 | 12/08-12/08/2003 | 123456789 | PAT | $375.00 | $2.00 | $373.00 | $.00 | $50.00 | $.00 | $161.50 | $.00 | $135.00 | $.00 | $26.50 | f | |||||||
| 4002205402 | DOE, J | e | 12/17-12/17/2003 | 123456789 | PAT | $138.00 | $.00 | $138.00 | $.00 | $.00 | $.00 | $69.00 | $.00 | $.00 | $.00 | $69.00 | f | |||||||
| 4002357102 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $79.16 | $.00 | $79.16 | $.00 | $.00 | $.00 | $39.58 | $.00 | $.00 | $.00 | $39.58 | f | |||||||
| 4002411202 | DOE, J | 1 | 02/09-02/09/2004 | 123456789 | PAT | $136.04 | $.00 | $136.04 | $.00 | $.00 | $.00 | $68.02 | $.00 | $.00 | $.00 | $68.02 | f | |||||||
| 4002614102 | DOE, J | 2 | 02/09-02/09/2004 | 123456789 | PAT | $50.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $25.00 | $.00 | $.00 | $.00 | $25.00 | f | |||||||
| 4002656802 | DOE, J | 3 | 02/09-02/09/2004 | 123456789 | PAT | $200.00 | $.00 | $200.00 | $.00 | $.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $100.00 | f | |||||||
| 4002891401 | DOE, J | s | 01/21-01/21/2004 | 123456789 | LAURA J | $113.00 | $.00 | $113.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $113.00 | f | |||||||
| 4002891601 | DOE, J | e | 01/21-01/21/2004 | 123456789 | PAT | $87.00 | $1.00 | $86.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $86.00 | f | |||||||
| 4002917501 | DOE, J | s | 01/22-01/22/2004 | 123456789 | PAT | $430.00 | $.00 | $430.00 | $.00 | $50.00 | $.00 | $190.00 | $.00 | $.00 | $.00 | $190.00 | f | |||||||
| 4002918101 | DOE, J | s | 01/17-01/17/2004 | 123456789 | PAT | |||||||||||||||||||