Catherine Rogers

 
 X-RAY BREAK DOWN FORM 
 Modesto Radiology Imaging 
 1524 McHenry Ave, Suite 100 
 Modesto, CA 95350 
 Phone: 565-395-2316
 Fax: 129-435-7087
 ATTENTION: 
 Firm: 
 EQUICOPY 
 Telephone: 840-340-4050 
 Patient: EDWARD FOSTER 
 Order Number: 184098-37 
 Date: 10-26-22 
 Jacket/Medical Record #: 76-40-02/324025 
 PLEASE NOTE!!! 
 date of service 
 Exam 
 Number of Films 
 28/08/15
 CT RT ANKLE 
 7-16 
 Films: $15.00 per sheet 
 Cds: $25.00 per CD (can copy multiple exams on CD) 
 0002
