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    Holly Randolph of 8902 Swift Rd, Austin, TX 77014 has a medical claim for services received on August 21, 2018 and September 8, 2018 at Lighthouse Medical Center located at 3275 Fry Rd, Austin, TX 77014. The claim includes procedure codes 47564 and 99233 for treatment of diagnoses M54.5, E66.9, and K21.9. The total amount due is $1803.00.

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    Holly Randolph of 8902 Swift Rd, Austin, TX 77014 has a medical claim for services received on August 21, 2018 and September 8, 2018 at Lighthouse Medical Center located at 3275 Fry Rd, Austin, TX 77014. The claim includes procedure codes 47564 and 99233 for treatment of diagnoses M54.5, E66.9, and K21.9. The total amount due is $1803.00.

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    © All Rights Reserved
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    2 views1 page

    cm8eDtduQBWdLy6ciBN3 - Cms 201500 20form

    Uploaded by

    Sesili Pipia
    Holly Randolph of 8902 Swift Rd, Austin, TX 77014 has a medical claim for services received on August 21, 2018 and September 8, 2018 at Lighthouse Medical Center located at 3275 Fry Rd, Austin, TX 77014. The claim includes procedure codes 47564 and 99233 for treatment of diagnoses M54.5, E66.9, and K21.9. The total amount due is $1803.00.

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    © All Rights Reserved
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    of 1

    Cigna

    13th Floor, 5 Aldermanbury Square, London EC2V 7HR

    00199739

    U524785461

    Holly Randolph 7 15 1975 Holly Randolph

    8902 Swift Rd 8902 Swift Rd

    Austin TX Austin TX

    77014 77014

    00054

    M54.5 E66.9 K21.9

    9 8 21 9 8 21 11 47564 A,B,C 1,478 00 1

    9 8 21 9 8 21 11 99233 A,B,C 325 00 1

    85-2178546 001358 1803 00

    3275 Fry Rd Lighthouse Medical Center


    Austin, Tx 77014 3275 Fry Rd

    145785421 145785421
    PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)

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