Donna May

 
 DIAGNOSTIC IMAGING SERVICES 
 4241 VETERANS BLVD 
 METAIRIE LA 70006 
 (540) 440-3400 
 Patient: 
 Donna May 
 PSC 8399, Box 1527
APO AA 06408
 Responsible party: 
 Donna May 
 PSC 8399, Box 1527
APO AA 06408
 Srvc. Date 
 Procedure Description 
 Location 
 Charge 
 Balance 
 Physician 
 Modifier (s) 
 Diagnosis Code (s) 
 2022 December 07 
 72141 - MRI, Cervical Spine s/ 5 - SLI 
 $2,000.00 
 $0.00 
 Satterlee, Arthur Jerry 
 M54.2 
 Payment Information 
 Insurance Payment (652 - DMA) : 2015 August 12 of $0.00 
 Adjustment: $1,425.00 
 Insurance Payment (652 - DMA) : 2018 September 20 of $575.00 
 Adjustment: $0 
 TOTAL BALANCE: $0.00 
 Print Date: 09/29/2023 
 Reproduced: Friday, September 29, 2023 04:17:46 PM (1pepp) 
 This report has been Reproduced from the Original 
 Reproduced Friday, September, 29, 2023 04:17:46 PM (1pepp) 
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