€14/28, 1:02 AM

Individual
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Servica Date ¥
4ey 23, 3528

May 35, 2

May 2, 2.

26

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Bar DY, 2226

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Ape G2, DO
Mor tH, 226

Mor 1, 2078
Mor 15, 2028

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Show Claims Within Service Date Range

asta

Dental

Name

Sack been

Bek
Mase hasta

Mara botany!

Mca betas

are tesanet
Back bolare)

Mak Botan

ark Hetact
Mare botaod

Merci tan

Mare Hote

Mase Natand

Expense/item
APCHENASTING TASLETS
SEXTOALINE

PME TULOOOAS ACL TAR
HEM

AWNE TARLETS
CUMATRESTEN
QRETIARKE
SERYRSUNG

PMS RISPERIDONE

PRS TRAZOOGNE HEL TAS
Ota

SUHATRIFTAN
APT SRLARTINE TASLETS.
QuETIANINE

DHS TRAIODONE HCL TAR
18S,

PHS-RISFERIOONE
SERTRALINE

PRS TRAZODONE HO. TAD
TORRG

Page 2 Total
Grand Total

Te

Amount Claimed Amount Paid Statement Date
$5214 May 29, 2076
SP7KS May 18, 2G
$3452 May 28, 226

$18.43 28, We

$tazs May 27, 2026
S555 Ape 28, 7026
Sib dpe 25, 2026
SIB7L Ape 28, 2826
SEAGS Ape 28, ING
SEAS Ape 28, IH

BSI Ape 7A, 207

B3S25 | Ape G1, 2075
$52.14 Ape at, 2076
BILE Ape Ot, NS
S462 Apr OL, 2026

2350 SEAS Ape Ot, BOs
SIA48 $1765 Ape 01, 2026
i382 S$tZ69- Mar $8, 2026
$18.45 $847 Mar 18, 2026
52437 $1872 Mar 38, 2026

$3,036.01 $1,114.48

$4,311,41 $2,004.16

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Detais
Betats
Detais

Detais

Detats

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