Contents - Index


Order/Invoice Input Summary

Order/Invoice Input Summary For 12/03/1996 - 12/03/1996          PG:1   
         Type                                           Total   Initial
Invoice# Inv.Date   Patient                            Amount Non-Allow
-------  -------- - --------------------------------------- ----------
17408    12/03/96 I 2322   COY, DALE A                         814.00          
   Procedure Code: L3250      ORTHOPEDIC FOOTWEAR, CUSTO    556.00
   Procedure Code: L3420      FULL SOLE AND HEEL WEDGE,      84.00
   Procedure Code: L3440      HEEL, COUNTER, LEATHER REI     94.00
   Procedure Code: L3030      FOOT, INSERT, REMOVABLE, F     80.00

17508    12/03/96 I 1297   PETERSON, NANCY                    3048.61          
   Procedure Code: L5652      SUCTION SUSPENSION, ABOVE     311.76
   Procedure Code: L5701      REPLACEMENT SOCKET AK/KD,    2736.85

17509    12/03/96 I 1297   PETERSON, NANCY                    9119.60          
   Procedure Code: L5310      KNEE DISARTICULATION (OR T   3840.36
   Procedure Code: L5613      ADDITION TO LOWER EXTREMIT   1752.43
   Procedure Code: L5622      TEST SOCKET, KNEE DISARTIC    287.23
   Procedure Code: L5631      ABOVE KNEE OR KNEE DISARTI    314.18
   Procedure Code: L5650      TOTAL CONTACT, ABOVE KNEE     349.08
   Procedure Code: L5652      SUCTION SUSPENSION, ABOVE     311.76
   Procedure Code: L5694      ABOVE KNEE, PELVIC CONTROL    129.73
   Procedure Code: L5696      ABOVE KNEE OR KNEE DISARTI    140.88
   Procedure Code: L5697      ABOVE KNEE OR KNEE DISARTI     66.92
   Procedure Code: L5705      REPLACEMENT CUSTOM SHAPE,     824.66
   Procedure Code: L5920      ABOVE KNEE OR HIP DISARTIC    379.40
   Procedure Code: L5950      ABOVE KNEE, ULTRA-LIGHT MA    556.33
   Procedure Code: L5974      FOOT, SINGLE AXIS ANKLE/FO    166.64

17731    12/03/96 I 6041   KOPISH, JOE E                       187.00          
   Procedure Code: A5500      DIABETICS ONLY, FIT/FOLLOW    155.00
   Procedure Code: A5505      DIABETICS ONLY, MODIF (INC     32.00

17740    12/03/96 I 1543   LEE, ROBERT J                      1868.00          
   Procedure Code: L2036      KAFO, FULL PLASTIC, DOUBLE   1338.00
   Procedure Code: L1960      AFO, POSTERIOR, SOLID ANKL    530.00

17745    12/03/96 I 3554   TREDER, TRICIA ANN                 3723.80          
   Procedure Code: L5700      REPLACEMENT SOCKET BK, MOL   2200.00
   Procedure Code: L5629      BELOW KNEE, ACRYLIC SOCKET    241.00
   Procedure Code: L5637      BELOW KNEE, TOTAL CONTACT     289.00
   Procedure Code: L5655      SOCKET INSERT, BELOW KNEE     259.00
   Procedure Code: L5668      BELOW KNEE, MOLDED DISTAL      94.00
   Procedure Code: L5785      EXOSKELETAL SYSTEM, BELOW     489.00
   Procedure Code: L8420      PROSTHETIC SOCK, WOOL, BEL    120.00
   Procedure Code: L8470      PROSTHETIC SOCK, SINGLE PL     31.80

17783    12/03/96 I 533    KNAPP, LAURA W                      100.00          
   Procedure Code: L4210      REPAIR OF ORTHOTIC DEVICE,    100.00

17794    12/03/96 I 6436   BELL, RICHARD                       625.00          
   Procedure Code: L1960      AFO, POSTERIOR, SOLID ANKL    530.00
   Procedure Code: L2830      ADDITION TO LOWER EXTREMIT     95.00
Order/Invoice Input Summary For 12/03/1996 - 12/03/1996          PG:2   
         Type                                           Total   Initial
Invoice# Inv.Date   Patient                            Amount Non-Allow
-------  -------- - --------------------------------------- ----------
17795    12/03/96 I 6415   WHITISH, JUSTIN                      95.18          
   Procedure Code: L0500      LUMBAR-SACRAL-ORTHOSIS,(LS     95.18

17796    12/03/96 I 6453   HEISER, NICOLE                      530.00          
   Procedure Code: L1960      AFO, POSTERIOR, SOLID ANKL    530.00

17798    12/03/96 I 370    MARQUARDT, STEVEN                  1168.00          
   Procedure Code: L1685      HO, ABDUCTION CONTROL OF H   1168.00

17805    12/03/96 I 2424   DENNER, CONRAD D                    755.00          
   Procedure Code: L1970      AFO, PLASTIC, MOLDED TO PA    647.00
   Procedure Code: L2200      ADDITION TO LOWER EXTREMIT    108.00

17830    12/03/96 I 6392   WILLIAMS, JAMES J.                   74.00          
   Procedure Code: L4210      REPAIR OF ORTHOTIC DEVICE,     74.00

17834    12/03/96 I 5361   SCHROUD, BURNELL D                  530.00          
   Procedure Code: L7500      REPAIR OF PROSTHETIC DEVIC    450.00
   Procedure Code: L7510      REPAIR OF PROSTHETIC DEVIC     80.00

17840    12/03/96 I 4463   VARELA JR., OSCAR J                  49.00          
   Procedure Code: L3999      UNLISTED PROCEDURES FOR UP     46.45

                                                            --------- 
                               TOTAL:            22687.19