Jose Williams

 Mountain View Medical 
 QED 
 STATEMENT OF ACCOUNT ( 0 ) 
 Page 1 
 326 Rodgers Lake Suite 922
South Evan, AR 51029
 Statement Date: 08/10/2021 
 TAX ID# 75-4057615 
 Account Number: QED16103796390 
 patient name: Jose Williams 
 Jose Williams 
 0457 Austin Throughway Suite 986
New Aaronville, OK 39067 
 Amount You Owe: 
 $0.00 
 Services provided at: 
 MEDICAL CITY LAS COLINAS - 6800 N MACARTHUR BLVD - IRVING TX 75039-2422
 Date of 
 CPT Code 
 Description 
 Provider 
 Charges 
 Payments or 
 Explanation 
 Amount 
 Service 
 Adjustments 
 You Owe 
 12/01/2019 
 27840 
 REDUCE ANKLE DISLOC W/O ANES 
 Dr Alexander Johnston 
 $3,082.00 
 $3,082.00 
 1,2,3,4 
 $0.00 
 12/01/2019
 99285 
 EMERG INJURY EVAL & MGMT-LVL 5 
 Dr Alexander Johnston 
 $1,516.00 
 $1,516.00 
 1,2,4 
 $0.00 
 Total Charges: 
 $4,598.00 
 Current Patient Responsibility: 
 $0.00 
 Insurance Information: 
 Insurance 1: BC/BS of Texas - TEXAS B/S ITS/OSS CLAIMS 
 PARHAM-0172 
 000001
