We have filed to your insurance already. You can pay for the statement amount due in MyDocBill.

Amount Due
$6585.69
RADIOLOGY ASSOCIATES OF NORTH
TEXAS
PO Box 1723 ACCOUNT OWNER
INDIANAPOLIS, IN 46206-1723 JAYLEN LITTLE
mydocbill.com/ratc
STATEMENT CREATED
1-888-965-1678 12/13/2022
1-877-718-5728
DUE DATE
ratcbilling@mydocbill.com Upon Receipt

Account Summary

INVOICE # PAYMENTS IN THE LAST 30 DAYS PENDING INSURANCE

10316201 $0.00 $0.00
ACCOUNT NUMBER STATEMENT AMOUNT DUE TOTAL AMOUNT BALANCE
12298662-QRATC $6585.69 $585.08

Guarantor Info

General Info Primary Insurance Info Secondary Insurance Info

JAYLEN LITTLE INSURANCE PROVIDER None
604 ELM FALLS PL
MESQUITE, TX 75181 ADDRESS

GROUP/PLAN

ID NUMBER

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Summary of Service Charges

PATIENT RENDERING PROVIDER SERVICE PROVIDED AT REFERRING PROVIDER

JAYLEN LITTLE ALVIN ANENE Methodist Mansfield Med Ctr ER BRIAN W TULBERT

DOS Proc Units Service Activity Charges Pay/ADJ Pending Balance

Code Insur

11/7/2022 71260 1 CT THORAX DX C+ $140.45 $0.00 $0.00 $140.45

11/9/2022
11/7/2022 70450 1 CT HEAD/BRAIN W/O DYE $102.40 $0.00 $0.00 $102.40
11/9/2022
11/7/2022 72125 1 CT NECK SPINE W/O DYE $121.23 $0.00 $0.00 $121.23
11/9/2022
11/7/2022 74177 1 CT ABD & PELV W/CONTRAST $221.00 $0.00 $0.00 $221.00
11/9/2022
11/7/2022 G9637 1 DOC>1 DOSE REDUC TECH $540.30 $0.00 $0.00 $540.30
11/9/2022
11/7/2022 G9637 1 DOC>1 DOSE REDUC TECH $540.30 $0.00 $0.00 $540.30
11/9/2022
11/7/2022 G9557 1 CT/CTA/MRI/A NO THYR<1.0CM $632.21 $0.00 $0.00 $632.21
11/9/2022
11/7/2022 G9551 1 ABD IMAG NO LES, KID/LIVR/ADR $432.00 $0.00 $0.00 $432.00
11/9/2022
11/7/2022 G9551 1 ABD IMAG NO LES, KID/LIVR/ADR $432.00 $0.00 $0.00 $432.00
11/9/2022
11/7/2022 364EX 1 MIPS MEASURE 364 EXCLUSION $570.33 $0.00 $0.00 $570.33
11/9/2022
11/7/2022 364EX 1 MIPS MEASURE 364 EXCLUSION $570.33 $0.00 $0.00 $570.33
11/9/2022
11/7/2022 G9637 1 DOC>1 DOSE REDUC TECH $540.30 $0.00 $0.00 $540.30
11/9/2022

11/7/2022 G9637 1 DOC>1 DOSE REDUC TECH $540.30 $0.00 $0.00 $540.30
11/9/2022

11/7/2022 G9557 1 CT/CTA/MRI/A NO THYR<1.0CM $632.21 $0.00 $0.00 $632.21

11/9/2022

11/7/2022 364EX 1 MIPS MEASURE 364 EXCLUSION $570.33 $0.00 $0.00 $570.33
11/9/2022

We have filed to your insurance already. You can pay for the statement amount due in MyDocBill.

If your insurance has issued payment directly to you, please send us this payment immediately to stop the collection efforts.
Please disregard this notice if you believe you have received it in error or if payment has already been made.

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