Todd Bowman

 
 X-RAY BREAK DOWN FORM 
 Modesto Radiology Imaging 
 1524 McHenry Ave, Suite 100 
 Modesto, CA 95350 
 Phone: 472-790-1095
 Fax: 366-714-4982
 ATTENTION: 
 Firm: 
 EQUICOPY 
 Telephone: 858-358-5850 
 Patient: EDWARD FOSTER 
 Order Number: 185898-37 
 Date: 10-26-22 
 Jacket/Medical Record #: 76-58-02/325825 
 PLEASE NOTE!!! 
 service date 
 Exam 
 Number of Films 
 Aug 20, 2014
 CT RT ANKLE 
 7-16 
 Films: $15.00 per sheet 
 Cds: $25.00 per CD (can copy multiple exams on CD) 
 0002
