| Invoice Number: | 138355 | | Billing Period: | 01/01/2007 - 01/31/2007 |
| Dental Group Number: | 20883-000-00000-28011 | | Group Name: | FULLY INSURED | | Master Number: | 00000 | | Description: | | | Phone Number: | (999) 999-0000 |
| FULLY INSURED | | 100 MAIN STREET | | ANYWHERE, USA 55555-0000 |
| PRIOR DUE |
|---|
| | Prior Amount Due | $ | 2,035.92 | | | | Less Payment Received | | 2,035.92 | | | | Balance From Prior Billing | | .00 | | | | | CURRENT DUE |
|---|
| | Total Subscriber Adjustments | $ | 163.36 | | | | Current Billed | | 2,339.88 | | | | Balance From Current Billing | | 2,339.88 | | | | | | Total Amount Due | $ | 2,503.24 | | | |
|
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